Introduction

It is common practice for naturopaths, nutritionists and other non-licensed practitioners to collect your signature on a form such as this. By doing so, you acknowledge and accept that we:

• are not medically qualified;
• are not a substitute for advice from a qualified doctor;
• recommend that you consult your doctor before making any changes to your diet or exercise regime or taking any dietary supplement;
• do not warrant the accuracy of any information provided;
• are not liable for any losses you may suffer by relying on our advice;
• do not recommend any particular product;
• are not a covered entity or a business associate of a covered entity under HIPAA.

By your signature below, and/or by instructing us to provide advice and services to you, you indicate your agreement to these terms.

What We Do and Do Not Do

We obtain a set of laboratory test results from a [Certified Laboratory in the United States] and provide you with a nutritional interpretation of those test results that you can use exclusively as an educational tool for personal health purposes.

Your doctor may use the same test results to diagnose and treat disease, but we do not do this. The information we provide is not intended to, cannot, and should not be expected to be a substitute for a personal consultation with your own qualified doctor. We do not accept any liability for any failure to identify any medical condition or disease; this is not the purpose of our services.

We may provide you with information relating to products that we believe might benefit you, but such information is not to be taken as an endorsement or recommendation. Some such products may not be available without a prescription, but we do not dispense or prescribe any prescription products. The information provided is intended for educational purposes only and should not be taken as professional medical advice or used as a substitute for medical care. We are not responsible for any adverse affects or consequences that may result, either directly or indirectly, from that information.

We will make reasonable effort to protect the privacy of your medical information that is shared with us, including any medical test results. However, that information is not protected by doctor-patient confidentiality nor is it governed by HIPAA.

Introduction

The parties,

(FDN Practitioner) and AFDNP Inc. hereby agree to the following:

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Agreement to Use FDN Medical Director Program

Whereas the FDN Practitioner desires to use information available on saliva, urine, stool and blood lab testing to help develop lifestyle & behavior programs for his or her clients, and whereas AFDNP Inc. can provide access to approved lab tests to FDN Practitioner's clients through the FDN Medical Director Program, the parties agree as follows:

FDN Practitioner may, only upon securing an approved “Terms of Service Agreement” with their client, order lab test kits to be shipped to the client.

As noted above, before ordering test kits on behalf of a client, FDN Practitioner is required to secure an approved Terms of Service Agreement which complies with HIPAA Regulations regarding privacy of client lab records. See the FDN Terms of Service Agreement for an example of a HIPAA Compliant agreement to secure and keep on file for all clients.

FDN Practitioner will instruct and assist client to follow directions provided with the lab kits for collection and submission of specimens and submission of submittal forms including payment in full for all lab fees. For convenience, most lab test kits include pre-stamped shipping materials for return-shipping to the lab test company.

The lab companies will forward electronic copies of lab reports to AFDNP Inc. or, in some cases, directly to the FDN Practitioner in full compliance with HIPAA Regulations. The FDN Practitioner may only use the data provided on the lab test reports to assist in designing lifestyle & behavior programs. FDN Practitioner may not use the information to provide a medical diagnosis or to treat any specific health condition unless he or she is licensed to do so.

Medical Director Program (MDP):

As an FDN Trainee, it is your responsibility to familiarize yourself with the MDP policies of the program. Violating the MDP policies may result in revocation of use of the program.

The FDN Medical Director Program was developed to be used by any licensed or unlicensed FDN Practitioner. This is a direct-to-consumer lab testing program used by FDN-Ps to facilitate lab testing for their clients authorized by the lab and our licensed Medical Directors. In all cases, the client is required to pay the lab fees directly to the lab company upon submittal of the specimen(s).

Many lab tests will incur a "Medical Director Fee” of $75 per test to cover administration, handling and expediting results and a review session. The list of tests which will incur this fee is noted on the MDP Test menu on FDNconnect.com. In such cases, the FDN Practitioner will receive a free appointment with an FDN Clinical Advisor (CA) to discuss the lab test results ordered under this program.

FDN Trainees are responsible for shipping their samples back to the lab according to the test kit instructions. This may include checking with local customs and researching local courier services that will successfully ship the lab specimens to its destination. Failure to do so may impact or void test results.

FDN Trainees are limited to ordering the labs taught in the course only for themselves until they graduate from the course program. These labs must be purchased prior to the Trainee’s R&R.

Some lab tests covered in this agreement (such as the FLUIDS iQ, NutriPATH, DUTCH, DHA Labs, MRT, and Neurotransmitter screenings) may be provided to the FDN Practitioner directly from the lab with no additional Medical Director fee cost, except for a possible shipping charge depending on where the client lives.

Some international labs also require a shipping fee paid directly to the lab before test kits will ship.

Upon receipt of lab test report for the client of an FDN Practitioner, AFDNP Inc will forward the lab test report to the FDN Practitioner, as well as instructions on how to make an appointment for an FDN Clinical Advisor call. If the FDN Practitioner desires to make an appointment with an FDN Clinical Advisor, he or she is required to submit his or her case notes, lab reports to be reviewed, and any other relevant information prior to the review call.

Note: FDN Clinical Advisor calls cannot be “banked”. A free CA call is provided for each lab test ordered through the MDP and the Medical Director Fees are charged on a “per kit” basis.

All inquiries about lab test reports will be via email to orders@afdnp.com or by calling 858-842-3266 Ext 6. FDN Practitioner shall refrain from contacting lab companies directly, as the FDN Practitioner is not a client of the lab company. Questions must be always directed instead to AFDNP Inc..

Under no circumstances shall an unlicensed FDN Practitioner provide diagnosis codes to a client for insurance billing purposes or for any other reason.

FDN Practitioner

Payment of Medical Director Program fee is due upon placing the order for test kits using a credit card on file. The card must be kept up to date by the FDN Practitioner. Test kits may be drop-shipped directly to FDN Practitioner client's address upon request.

FDP Practitioner is responsible for indicating the correct client name and address for each test ordered and should not switch the test to another client. Failure to comply with this policy will delay turn-around time and reflects poorly on the FDN Practitioner.

FDN Practitioner is an independent contractor and is responsible for reporting lab test results to his or her clients along with any self-treatment recommendations.

FDN Practitioner acknowledges that AFDNP Inc. and its agents provide lab findings and educational information only, and do not provide medical diagnoses or treatments for any medical conditions.

FDN Practitioner warrants that he or she uses laboratory test results for educational and research purposes only and not for the purpose of diagnosing or treating any specific medical condition(s).

FDN Practitioner will refer his or her professional clients to a licensed health care provider for any medical interpretation of test results or medical diagnosis and for any medical opinion or possible medical treatment.

FDN Practitioner warrants that he or she shall maintain compliance with all laws of his or her local, state and federal government and agencies regarding the scope of nutrition and health coaching and consulting practices, including use of nutritional supplements.

Violation of any of these terms and conditions shall be determined a breach of this agreement and suspension of FDN Practitioner’s privileges for the purpose of ordering laboratory testing through the MDP.

I understand that AFDNP Inc. can cancel this Lab Service Agreement at any time.