Paragon Total Wellness - Intake Form
Patient Demographics & Contact Information
Preferred Contact Method
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Primary Care Provider (if applicable)
Do you currently have medical insurance?
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Upload image of front/back of card (if digital form)
Note: Paragon Total Wellness is a cash-based practice. Insurance information is collected only to assist with referrals or to provide you with superbills for additional services when appropriate.
Notice of Privacy Practices
Effective Date: May 1st, 2025
Practice Name: Paragon Total Wellness
Address: 7500 North Dobson Road, Suite 101, Scottsdale, AZ 85256
Phone: 480-372-3032
Email:
[email protected]Your Rights. You have the right to:
- Get a copy of your medical record.
- Correct your medical record.
- Request confidential communication.
- Ask us to limit the information we share.
- Get a list of those with whom we’ve shared your information.
- Get a copy of this privacy notice.
- Choose someone to act for you.
- File a complaint if you believe your privacy rights have been violated.
Your Choices. You can tell us your choices about:
- Sharing information with your family, close friends, or others involved in your care.
- Sharing information in a disaster relief situation.
- Including your information in a patient directory (if applicable).
- Contacting you for fundraising efforts (we will always give you an option to opt out).
- Marketing or sale of your information (only with written authorization).
Our Uses and Disclosures. We typically use or share your health information to:
- Treat you (e.g., sharing info with other healthcare providers).
- Run our organization (e.g., improving care quality).
- Bill for your services (even if you pay out-of-pocket, we may need to create documentation or superbills).
We may also share your information:
- With public health authorities for reporting diseases, injuries, or vital statistics.
- For health oversight activities (e.g., audits or investigations).
- With law enforcement if required by law.
- To respond to legal actions (e.g., subpoenas or court orders).
- To prevent serious threats to health or safety.
- Sell your information without your written authorization.
- Use your information for marketing without permission.
- Share psychotherapy notes unless you authorize it (if applicable).
- We are required by law to maintain the privacy and security of your protected health information.
- We will notify you promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice.
- We will not use or share your information other than as described here unless you tell us we can in writing. You may revoke your permission at any time.
We may change this notice at any time. If we do, we will post the updated notice in our office and on our website, and make copies available upon request.
If you believe your privacy rights have been violated, you can contact:
Privacy Officer
Paragon Total Wellness
Email:
[email protected]
Phone: 480-372-3032
- You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights.
- We will not retaliate against you for filing a complaint.
Acknowledgement of Receipt of Privacy Notice
- I hereby give consent to Paragon Total Wellness to use and/or disclose my protected health information for the purposes of treatment, payment, and healthcare operations.
- I acknowledge that Paragon Total Wellness has provided me with a copy of its Notice of Privacy Practices, which describes these uses and disclosures in detail. I have been given the opportunity to review this notice prior to signing this form, in accordance with my right to review the practice’s privacy policies before granting consent.
- I understand that the terms of the Notice of Privacy Practices may change over time and that I may request a revised copy at any time. Paragon Total Wellness is committed to maintaining the confidentiality and privacy of my health information. A copy of the Privacy Policy has been emailed to me; if I would like an additional copy, I may request one from the front office.
- I understand that I have the right to request, now and in the future, restrictions on how my protected health information is used or disclosed to carry out treatment, payment, and healthcare operations. While Paragon Total Wellness is not required to agree to these requested restrictions, if it does agree, it is bound by that agreement.
- This consent will remain in effect for as long as I am a patient at Paragon Total Wellness. I understand that I may revoke this consent at any time in writing by sending such notification to my provider at the practice. Such revocation will not affect disclosures made prior to the receipt of the revocation.
By signing this form, I acknowledge that I have received and reviewed the Notice of Privacy Practices
Authorization for the Use or Disclosure of Protected Health Information (PHI)
By signing this form I give consent for the use and disclosure of my protected health information as outlined.
To have access to the following information in my records at Paragon Total Wellness (check all that apply):
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To have access to the following information in my records at Paragon Total Wellness (check all that apply):
- I may revoke this authorization at any time in writing.
- Revoking this does not apply to any information already disclosed.
- My care will not be impacted by my decision to sign or withhold this authorization.
Patient (or legally authorized individual) Signature
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Financial Agreement & Payment Policy
- Paragon Total Wellness operates as a direct-pay, cash-based practice. We do not bill insurance and do not participate in any insurance networks.
- Services are on an annual subscription basis and payment is due on an annual basis unless otherwise arranged in writing.
By Signing below, I understand and agree that:
- I am financially responsible for all services rendered.
- Services are on an annual subscription basis and payment is due on a monthly basis unless otherwise arranged in writing.
- I may request a superbill for reimbursement from my insurance, but reimbursement is not guaranteed.
- Acceptable payment methods include credit/debit card, cash/cashier’s check, money order or CareCredit, HSA/FSA, or other approved methods. Personal checks cannot be accepted for payment.
- Missed appointments without 24-hour notice may incur a cancellation fee.
- All annual membership fees are non-refundable, regardless of early cancellation or discontinuation of services.
- Any unpaid balances older than 30 days may be subject to late fees and collection activity.
- Questions regarding billing should be directed to
[email protected].Informed Consent for Care
I voluntarily consent to receive medical, wellness, fitness, and lifestyle-related services provided by Paragon Total Wellness. These services may (but are not limited to) include:
- Preventive medical care and health optimization
- Nutrition and fitness counseling
- Laboratory and physical assessments
- Wellness coaching and behavioral health strategies
- These services are not a substitute for emergency or specialty care.
- Risks, benefits, and alternatives will be discussed with me before any procedure or significant treatment.
- I may refuse any recommended service or treatment.
- My care is collaborative, and I am encouraged to ask questions at any time.
- I understand that Paragon Total Wellness does not bill insurance and that I am responsible for the costs associated with my care.
By signing this form, I confirm that:
- I have had the opportunity to ask questions about my care.
- I understand the nature of the services provided.
- I consent to care provided by Paragon Total Wellness.