New patient registration

Assignment of benefits

I authorize the release of any information concerning my (or my child's) health care, advice and treatment provided, for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor. I understand that my eligibility for coverage may not be able to be confirmed at this time. I wish to receive medical services from MARIANA BUBUCEA MD PA. If it is determined that I am not eligible for coverage, I understand that I will be responsible for payment of all services provided.

Copayments and self-payment

Each patient is required to make their copayment or self-payment before leaving the clinic. Payment is accepted by cash or card. A blood draw performed in our office carries a $35 fee. If you receive a bill after your visit due to co-insurance under your plan, it is your responsibility to call the office and make the payment; outstanding balances are sent to a collection company.

Laboratory billing

I understand that Dr. Bubucea may order laboratory testing for the condition I am being seen for. If I choose to use my insurance to cover this testing, the unpaid balance is my responsibility, not the office's. Please do not bring lab bills to the office for resolution — labs not paid by insurance must be discussed with the insurance company directly.

Refund policy

By purchasing services and/or products from Dr. Mariana Bubucea Clinic, I acknowledge and consent to the following: there are no refunds of amounts paid for services or products; only exchange of services or products is accepted. An administrative fee of 10% of the registration cost is charged for all approved refunds. A refund may be considered in the event of a medical emergency, illness or other exceptional circumstance, upon submission of valid verifiable documentation. Approval is not automatic and is subject to individual review. Please allow up to 48 hours for review and response.

Deposits, appointments and cancellations

Consultation appointments must be cancelled at least 48 hours in advance. Cancelling a consultation less than 24 hours before the appointment incurs a $50 fee per 30 minutes booked — a 60-minute consultation cancelled late is a $100 fee. No further appointments will be scheduled while fees remain outstanding. It is my responsibility to inform the office of any change to my address or contact information.

Procedure appointments must be rescheduled at least 5 business days in advance. A 30% deposit is required to schedule any procedure (for example EBOO, TPE, pellet insertion, labiaplasty, mole removal). The deposit confirms the date and time of your appointment. On a first cancellation, 25% of the deposit is withheld; on a second cancellation the entire deposit is non-refundable. Example: for a $1,000 service the deposit is $300; a first cancellation withholds $75, a second cancellation withholds the full $300. Please confirm, reschedule or cancel at least 24 hours in advance. If you do not confirm your visit or do not answer calls and messages, the office may cancel your booking. After one no-show, the office reserves the right to deny future appointments.

New prescriptions and refills

All new prescriptions require an office visit. It is your responsibility to call the office during working hours (9 a.m. to 5 p.m., Monday through Friday) before you run out of your medication. We do not provide emergency appointments for patients who did not call in advance. When you call, please have ready: the name of the medication, the dose, and your pharmacy's name and telephone number, plus a number where we can reach you. Allow 72 hours for phoned-in refill requests to be processed, and check with your pharmacy before calling us back. Please call 3 days before your medication runs out. Controlled substances will not be called in or faxed to the pharmacy.

Laboratory results and diagnostic tests

All laboratory results and diagnostic testing must be reviewed with the doctor in person, which requires a scheduled office visit. Results will not be reviewed over the phone. If you request results that need discussion or further treatment before the appointment time, you automatically relieve Dr. Bubucea of any legal or medical responsibility, with no opportunity to reschedule your appointment.

Forms and letters

Forms that need to be completed by the doctor require two weeks' notice. You must drop the form off at our office with all of your own sections already completed, and you will be contacted when it is ready for pick-up. Letters written on your behalf require the same processing time; please call the office and tell the staff the specific details that need to be included. Forms and letters cannot be processed during your appointment. In many cases there may be an additional charge and/or an office visit required to complete forms.

Patient conduct and termination of care

Our practice is committed to providing a safe, respectful and professional environment for patients, staff and providers. The office reserves the right to refuse or discontinue care, cancel scheduled appointments, or discharge a patient from the practice if the patient demonstrates disruptive, inappropriate, abusive, threatening or unsafe behavior. This includes, but is not limited to, verbal abuse, aggressive behavior, harassment, intimidation, refusal to follow office policies, or behavior that interferes with the delivery of care or the safety and well-being of others. In such cases the practice may immediately terminate the patient–provider relationship. When required by law, appropriate notice and/or referrals will be provided. The decision to discharge a patient is made at the sole discretion of the practice.

Notice of Privacy Practices

Effective date of this notice: January 7, 2005

This notice is provided as required by the privacy regulations created under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). It describes how health information about you may be used and disclosed, and how you can get access to your individually identifiable health information. Please review it carefully.

A. Our commitment to your privacy

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (PHI). In conducting our business we create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you, and to provide you with this notice of our legal duties and the privacy practices we maintain concerning your PHI. By federal and state law we must follow the terms of the notice of privacy practices in effect at the time.

We must provide you with the following important information:

• How we may use and disclose your PHI
• Your privacy rights in your PHI
• Our obligations concerning the use and disclosure of your PHI

The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment will be effective for all records our practice has created or maintained in the past and for any records we create or maintain in the future. A copy of the current notice is posted in our office in a visible location at all times, and you may request a copy at any time.

B. If you have any questions, please contact

2500 E Hallandale Beach Blvd., Suite 401, Hallandale Beach, FL 33009
Tel: 786-775-0626

Consent for treatment

The doctor uses a combined treatment approach that may include both conventional and non-traditional integrative modalities, when deemed appropriate for the patient's condition. Dr. Mariana Bubucea incorporates integrative therapies and complementary approaches within the scope of her medical practice and specialty.

Pelvic examination informed consent

I understand that by law my health care practitioner requires written informed consent to perform a pelvic examination on me, and I have been informed that I will be receiving a pelvic examination.

A pelvic examination means an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum, or external pelvic tissue or organs, using any combination of modalities which may include, but is not limited to, the health care provider's gloved hand or instrumentation.

I have been informed as to the nature and process of the pelvic examination. Any and all questions have been answered to my satisfaction.

Informed consent — integrative and injectable therapies

I hereby request and consent to examination and to subcutaneous and/or intramuscular injection of vitamins and peptides, as well as treatment with naturopathic care, including various modes of elective vitamin and peptide injection and bioidentical hormone replacement therapy, for me (or for the patient named below, for whom I have legal authority to act) by Dr. Bubucea. Naturopathic evaluation includes commonly used physical examination to help determine the diagnosis and course of treatment. I understand that I am in full control of my body during the examination, and that it is my responsibility to inform the healthcare provider of any procedure that I feel may cause injury or that I want stopped. As a patient I have a right to be informed about my condition and recommended care; this disclosure is to help me become better informed so that I may decide to give or withhold my consent to any proposed treatment.

I understand that evaluation and treatment may include, but is not limited to, various modes of physical therapy (ultrasound, oxygen therapy, bioidentical hormone replacement, subcutaneous and/or intramuscular injection of vitamins, minerals and peptides, treatment with exosomes, Sculptra and other fillers for face and body, etc.), collecting specimens for laboratory evaluation including blood draws, ordering diagnostic imaging and tests, prescription of certain medications and nutritional supplements, counseling and dietary therapy, and homeopathic medicines referred to as remedies.

I understand that the U.S. Food and Drug Administration has not evaluated or approved peptides, herbal and homeopathic supplements, although they have been widely used in Europe and the United States for many years. I also understand that, as with drugs, nutritional supplements, vitamin injections, bioidentical hormone replacement, and herbal and homeopathic remedies may cause side effects in certain individuals, may interact with certain allopathic medications or lab tests, or may produce symptoms due to pre-existing conditions. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment in recommending treatments that she feels at the time, based on the facts then known, are in my best interest.

I have had the opportunity to ask questions and to discuss with Dr. Bubucea, to my satisfaction: my suspected diagnosis or condition; treatment options and reasonably available alternatives; the nature, purpose and potential benefit of the proposed care; the inherent and possible risks, complications and side effects of the treatment; the probability or likelihood of success; recommended follow-up care; and the possible consequences if treatment or advice is not followed or nothing is done. I understand that in the practice of naturopathy there are some risks of examination and treatment, and I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatment. I intend this consent to cover the entire course of treatment for my present condition and for any conditions for which I seek treatment in the future.

Peptide therapy consent

Peptides are small chains of amino acids that can have biological activity and are mostly naturally occurring. Some peptides are FDA approved for the treatment of certain diseases; other peptides used clinically are prepared by duly registered compounding pharmacies complying with all state and federal laws. Peptides can be administered by oral, intravenous, subcutaneous, intramuscular and intranasal routes, among others.

My physician, Dr. Bubucea, is allowed to discuss with me the possibility of integrating peptide therapy into my current treatment regimen. I understand that the use of these peptides is not necessarily approved for my medical conditions, and that my physician is providing this as a complement to my current treatments, following the principles of the practice of medicine and the laws regulating compounding pharmacies.

As with any other drug, peptide therapies can have side effects, including but not limited to:

• Nausea
• Vomiting
• Fever
• Injection site reactions (pain, rash, bleeding)
• Allergies, including life-threatening allergies
• Additional side effects not listed may also occur

Alternatives to peptide therapy are:

• Do nothing
• Standard medication use
• Surgery or other therapeutic intervention

I understand that peptide therapy is being used as part of an integrative treatment approach. Having read this, I acknowledge that I am voluntarily undergoing peptide therapy and that I hereby relieve Dr. Bubucea of any legal responsibility regarding side effects or complications that may occur from receiving peptide therapy. I certify that if any concerns or side effects occur I will promptly notify Dr. Bubucea. I also understand that Dr. Bubucea is not responsible for manufacturing issues related to these peptides, such as sterility and potency, which are the sole responsibility of the compounding pharmacy preparing them.

Your attestation