Global Immunotherapy LLC.



Zoom Meeting or Telephone Consultation Contact Information FormPatient Name:Mailing Address:Date of Birth for the patient:Telephone #:Time Zone:Once we confirm an appointment you will be sent the Zoom Meeting information where YOU will call-in or log-on for the meeting. Payment Method: ACH Bank transfers are free. Credit card transactions will incur a fee, see below.ACH Bank Transfer (only available for US banks): YES NOOr Credit Card: (you are agreeing to the service fee of 3.4% by selecting credit card)YESNOOr PayPal (US Bank Transfer free, Domestic CC 2.9%, International CC 4.4%) you will be sent a PayPal request after your call.Billing name & email:Would you like your Zoom call recorded and emailed after the appointment? If so, please remind Dr. Vincent to record the meeting.YESNOWould you like an expedited appointment? (The expedited appointments are $1200.00 for a one-hour consultation or more if you exceed the hour.) YESNOOnly email LDI or LDA Records, no other medical records are needed. After your appointment you will be emailed your invoice, at which time you will review and pay online. Check your mailing address on the invoice prior to payment, do not pay the invoice if it is not correct.**Please complete this form only and e-mail it back. Your appointment cannot be secured until this form is received. By signing and returning this form, you agree to the terms of Dr. Vincent’s fees. We will not ship doses until fees are paid through our emailed invoice system that allows you to pay via bank transfer, credit card, or PayPal. Your appointment fee will be determined on the time spent on the call. New Consults are $800 (1 hour) or $1200 for expedited appointments minimum or more depending on the length on the call if over an hour. The remaining forms are for your records. Please note there will be a $25.00 fee for all rejected ACH bank transfers/electronic checks or rejected credit card payments. Date: How did you hear about Dr. Vincent and what brings you to schedule with him?Signature (electronic signatures accepted):Fees: Zoom meeting/Telephone Consultations: New Consultations are $800.00 or more based on the length of time of the visit. We schedule new consultations for 1 hour, and $800. Keep in mind if you exceed the hour, Dr. Vincent will charge for his time over the hour. The dose fee is in addition to the consultation fee.Follow-ups: Billed at his $800 rate, on length of time of the appointment. Please, be advised billing is based upon the time spent with a client for follow-ups, not a set fee with the exception of New Consultations, they are $800 minimum, or more. Expedited Zoom/Telephone Appointments: If you prefer to have an expedited appointment on the first available weekend/holiday, Dr. Vincent will take appointments on his scheduled days off or extend his day for visits. These appointments are for those who do not wish to wait for the first available new patient appointment due to Dr. Vincent becoming booked out. These appointments are by request/preference, please indicate on your form if you’d like this option. The new consultation fee is $1200.00 for the one-hour new patient visit minimum. If you exceed the one-hour time, he does charge for his time over the hour. The dose fee will be in addition to the consultation fee.Treatment Review/Dose Fee:Treatment Review/Dose fee will be as follows: 1-5 syringes-$150 per person each dose cycle. We will send up to 2 core doses per shipment.$25 for each additional syringe past 5, each dose cycle. *The treatment review fee is a bundle fee to encompasses the time to review your dose response, give feedback on the next step, preparation of the doses, and both Dr. Vincent and Jinette’s time to do those things. *Please, understand this is a customized treatment plan. The way a patient and Dr. Vincent decide the number of syringes, and if they are combined or separate are up to patient/Dr. Vincent. Do not pay your invoice until it reflects your desired dose plan, per the conversations you have with Dr. Vincent, email Jinette with any questions or inaccuracy on the invoice, including mailing address. The invoice reflects what will be shipping and in what manner, please help us, help you. The LDI Patient Handout details how doses are written including separate or combine syringes. For services or sales taking place in the State of Hawaii please note all fees are subject to State of Hawaii Excise Tax.*Shipping cost will be separate, due to the variable cost associated with each location.Deposit: A $200 non-refundable deposit may be required to secure your appointment. I will let you know if you will need to make a deposit due to cancellations or rescheduling at the last minute. If you need to reschedule, a 24-hour notice is required via email to customerservice@. If you fail to notify us, you will forfeit your deposit due to the late notice cancellation. You will then be required to make another $200 deposit if you choose to reschedule. If you maintain your appointment or reschedule prior to the 24 hours your account will maintain your $200 deposit to use toward your appointment. *The New Consultation and dose fee include all ongoing dose report communication. LDI requires dose reporting every dose you will take and this is included. If your medical conditions change or require elaborate communication only then will Dr. Vincent recommend a follow-up or require the communication to be billed. Please call with questions. We are able to answer most questions free of charge but reserve the right to require billable communication if the situation changes and requires further or more elaborate communication.LDA/LDI Dose Summary Reporting: There is no charge to review and prepare your next doses based upon the reporting instructions provided by Dr. Vincent in the Patient Handout. The initial consult and dose fees include this continued direct communication with Dr. Vincent throughout your care when dose reporting.Questions before/after the visit: Dr. Vincent will only need LDI or LDA records. If you send all medical records and would like them reviewed before a visit, that time will be billed. They are not necessary in most cases, and questions can be covered during the visit.If you email unrelated or detailed medical questions you can receive answers from Dr. Vincent, this time is billed. Do not call the office with medical questions related to your care, you will be directed to email Dr. Vincent. You have the option to schedule a follow-up or email questions if you need medical answers. All medical questions should be directed to dr.vincent.ldi@. There is a $50 minimum charge for emailed questions outside the typical dose reporting, you will be emailed in such cases that there is a fee to respond. Keep in mind Dr. Vincent covers most questions with dose reporting, however to protect his time, this is our policy. All other questions related to finding information, invoices, payments, scheduling etc. need to be emailed to Jinette at customerservice@. Contact InformationEmail is preferred, via customerservice@ or call (907) 671-8255. We are a virtual office and typically answer emails 7 days a week. E-mail is the best way to communicate or request a call. The office is open for calls T, W, Th and F- 9 a.m. to 2:00 p.m. Hawaii Standard Time, email: customerservice@, for all billing, scheduling questions, and inquiries. Please keep in mind we are a home-based office, Jinette will return calls as quickly as possible.dr.vincent.ldi@ to report your dose response summary only. Do not send multiple reports for the SAME DOSE, or multiple emails for the same issue or question. Collect all information and send 1 email with your summary. If you send multiple dose reports, followed by multiple questions for the same dose it creates confusion. If you send multiple emails about the same thing, it causes confusion and substantial delays in your care. You will end up waiting longer for answers, as Dr. Vincent responds in the order received., (907) 671-8255 Hawaii Standard Time Facebook: Global Immunotherapy To View videos and new information YouTube: Global Immunotherapy. All of Dr. Vincent’s videos are available there. LDA/LDI Dose Response SummaryFollow these steps after you take your Dose, and you are ready to report.Email to dr.vincent.ldi@Please follow these instructions to ensure accurate communication and timely preparation of your next dose. The accuracy of your summary determines your success. Please read all instructions.Watch Video 11, LDI/LDA Reporting Instructions, prior to taking your dose. You may access Video 11 on our Facebook page, YouTube and our website . Read the ENTIRE LDI Patient Handbook that is emailed when you inquire about scheduling.Take your dose, and immediately record the date. Get a paper calendar, it’s the best way to keep an accurate record of the dose taken, and on what date.Keep a daily record (for yourself only) of how your symptoms deviate from your normal baseline. How you felt prior to you taking any LDI or LDA is you baseline.On day 7 after taking your dose, you will email Dr. Vincent how you responded. Please place the Patient name in the subject line. You must list the complete dose name (found on the invoice and on the syringe you have taken) and date you took it in “MM/DD/YYY” format. You must tell Dr. Vincent if a symptom got better, worse or stayed the same from your bassline. Most common responses are “no change” when we first begin, so don’t over think it. Do not write an elaborate description of your symptoms. We need the overall change. If things got better or worse, only then do we need to know by what degree they were better or worse.Email your completed dose report to dr.vincent.ldi@. You will receive an auto-reply back indicating we received it once a week. This places you in the “virtual line,” for dose communication with Dr. Vincent, allow 72 hours for a response. If you call with medical questions you will be instructed to email, or you can schedule an immediate follow-up consult to skip the wait. Keep in mind, there are not any medical emergencies related to LDI or LDA. If you are having a medical emergency call 911 or seek a local doctor. Dr. Vincent cannot do anything through telemedicine, nor are there LDI or LDA related emergencies.Dr. Vincent will review your case and suggest your next doses, once you agree, please indicate you’re ready for your invoice by replying to customerservice@ (Jinette’s email.) This step gets missed. Jinette is in charge of sending the invoice. Simply respond, with the DOSE PLAN included, saying you agree to the plan, and then she will send the invoice via email. If there is ever longer than 24 hours from agreeing to a plan and you have not gotten your invoice, please email Jinette. I will occasionally drop the ball and friendly reminders are always welcome.You will be emailed an invoice from Intuit to pay for your next dose plan (allow 24 hours or email Jinette if you don’t see it.) You may pay via the “Pay Now” link. Submit payment with Credit card or bank transfer. Once your invoice is paid your doses can be prepared. Allow 3 days for the payment to process. There is a $25 fee for rejected payments.Once your doses are shipped, we will send you an email with tracking information from .We must work together to ensure dose reporting is done in an efficient manner so the next dose will arrive prior to the date you need it. The more efficient and succinct your communication the faster and better service you will receive. In the event Dr. Vincent or Jinette do not respond within the time they indicate, please email Jinette at customerservice@. Dr. V and I occasionally miss an email so don’t hesitate to give a friendly reminder if we don’t respond within our projected times. Allow 72 hours for Dr. Vincent and 24 hours for Jinette.FAQ:What is LDI and LDA? Please watch Dr. Vincent’s YouTube Video’s, he explains it far better than I do.How far is he booked out? Currently 16 weeks, indicate on your New Patient form if you would like to be added to the cancellation list.What do I do before my appointment? Watch his video on what to expect before a visit, and download and test out the Zoom meeting platform.Do you need my labs? No, and please do not send them. He does not need them, and if he does, he will ask. What records does he need? Only LDI and LDA records. The last 3 doses and dates are most important.When do I pay? You will be emailed the invoice after the appointment. It will come from Global Immunotherapy, check your junk mail if you don’t see it, and look for it within 24 hours of the appointment.D you take Insurance? No. Nor can we give out diagnostic codes for patients not seen in person.What is ACH payment? It is an electronic check. YOU will provide your account and routing number (located at the bottom of a check) on the secure payment screen sent from Intuit/Global Immunotherapy.What is Zoom? Zoom Meeting is a virtual meeting platform (HIPPA compliant) that allows a face-to-face conference. All you have to do is put the meeting link into your browser, and you are signed-on and ready to go. You may need to download the application. We will email the link to you prior to your appointment. Very easy, no passwords, no hassle. Where do I dose report? To Dr. Vincent at dr.vincent.ldi@Can I track my shipped doses? Yes, you will get tracking from . DO NOT reply or ask questions to this email, as this is a third party. Jinette: customerservice@ for all the business questions, and Ty at dr.vincent.ldi@ for the medical questions and reports. ................
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