Brigette's Natural Healthcare Research and Laboratory Division
 

Brenda Nelson-Porter, ND, DM, MIT, Lab Director

CLIA-CERTIFIED WAIVED NATURAL TESTING LABORATORY

APPLICATION FOR NATURAL HEALTH COMMUNITY-BASED SCREENING CARE
~If you are currently experiencing a medical emergency, call 911~

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Initial Client Visit

I understand this natural healthcare service provider (Brigette's Natural Healthcare Research and Laboratory Division-NPI)
is to provide said name Client with findings and suggestions that may approach the underlying cause(s) of the symptoms indicated in this form submission.

I also understand this is a natural healthcare screening and data analytics service support
and not the traditional medical service provider who diagnoses, treats, or alleviates diseases or the effects of diseases
and/or administers conventional prescription medications [Firm's detailed Disclaimer].
This natural support follows HIPAA laws.

I understand waived analytes tests will used for this screening service based on "medically necessary" criteria
and the kit and lab fees may not be covered by insurance companies.

I understand since home-based waived test kits will be used; no eating, drinking (to include alcohol), or smoking for 1 hour (or as indicated in the manufacturer policy) prior to collection.

Call for initial appointment time and return here and complete this online application (in English): 770-365-7577
Mail or Email Copy of Photo ID and Insurance Card: Email Subject Line: Initial Client Visit--Waived Testing: [Full Name]

If the patient desires future services beyond this initial visit, click here:
 

Do Not Type In This Box

Client Full Legal Name:       Current Title:

Client Contact Information (Physical Address):

Client Contact Information (Electronic):

To maintain confidentiality, the email above is where medical information will be emailed; provide an email where others do not have access.

Here, specify the focus of your visit requesting. If left blank, these factors may not be considered for the findings:

SSN:     Client ID/Source (indicated on physician/hospital record):

Age/DOB:      Weight:      Height:   

Gender:     Race:        Blood Type:     Eye Color:    

Early Warning Signs (EWS)

Oxygen:         Temperature:    

Last Blood Pressure:     Level of Consciousness:
 

Medical History

Recent Blood Work From Primary MD (Results):

Recent Comprehensive Metabolic Blood Prick/Swab/Urine Analysis From ND (Results/NA):

Conventional Medications Current Intake (Reason/Dose/Frequency) Effect:


Medication Allergies:

Food Sensitivities/Allergies:  
 
Complementary Remedies/Natural Supplements Current Intake (Reason/Dose/Frequency) Effect:

Medical History [indicate ICD-10 code (s) if known] [indicate if you have had a previous genetic testing and have a report]
 

Liver damage:    
Heart damage:
Cancer/Tumor: (Stage/Dimension):   

    Diagnostic Test: Mammogram/CAT/MRI/PET/Bone Density/X-ray/Ultrasound/Nuclear Scan (State/Date/Results):
   

    Cancer Treatments at/by MD:

Recreational Habits (Alcohol/Tobacco/Street Drugs & Frequency):

Food Consumption Preference: Vegetarian, Vegan, Semi-Vegetarian/Pescetarian, Omnivore (select one):  

Religion/Spiritual Beliefs:

Family Medical History:

Medical Physician (private/active military MD)


Medical Physician (private/active military OBGyn)

Medical Physician (VA Provider)


Caregiver (Home-Based Agency Caregiver)


 Caregiver (Home-Based Agency Caregiver)


Research:

For Service Professionals w/ Private Occupations: First, we should always thank service members for their service. Complete All that applies:

PSTD Origination (War Zone/Other):   Year PSTD Diagnosed By Licensed MD/Therapist: 
Other Trauma:   Year Diagnosed by a Licensed Psychiatrist/MD): 

Veteran Disability (w/Rating):   
VA Disability Claim:

Instructions: Type Your Explanations After Each Question. Do Not Remove the Text in the Textbox:



Service Cost:

Primary Private Insurance:   

Secondary Insurance (Medicare/Medicaid/VA):

Next of Kin Name/Phone Contact In Case of Emergency:

Date of Initial Appointment:

Client Electronic Signature (full name/last 4 of ssn) :

Caregiver Signature (only sign if Lab Client is unable to sign):
 

After pressing "Submit" print your confirmation page twice, one to mail/email via pdf to the Firm and one to maintain for your records.
Mail to: Brigette's Natural Healthcare Research and Laboratory, 105 Wilson Circle, Newnan, GA  30263 USA

 



 

REIMBURSEMENT NOTICES

AETNA [Medicare (PPO)]: The standard CMS-1500 or UB-04 form will be used.

BCBS (ANTHEM): To be considered for reimbursement of clinical laboratory services, a valid CLIA certificate identification number must be reported on a 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent effective July 1, 2015.

CIGNA: To submit, clients should complete the Medical Claim Form and send bill with this form if Cigna does not reimburse via other means.

UNITED HEALTHCARE:  For purposes of this policy, a valid CLIA Certificate Identification number will be required for reimbursement of clinical laboratory services reported on a1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent.

GOVERNMENT: The CMS-1500 Form is used by individual professional health care or health care related providers to file for reimbursement of civilian health care services or supplies provided to TRICARE beneficiaries. This is the national standard claim form accepted by all major commercial and government payers.

HRSA (Health Resources and Services Administration; U.S. Department of Health and Human Service)

Government Employee Health Association (GEHA): Federal regulations require that a claim submitted by a provider must be filed on a CMS-1500 GEHA form.

Medicare: Screenings

TELE-HEALTH: Georgia
 

Medical Laws Weblography


 

OTHER SERVICES AND INFORMATION

       

        

       

       
 


 

The Firm Would Appreciate Your Participation In The Frim's Research Projects If Applicable.

         

Brigette's Technology Consulting and Research Firm ©2004-2022
Brigette's Natural Healthcare Research and Laboratory Division
©2020-2022
All Rights Reserved Worldwide