Apply to Work With Us Functional Primary Care Advanced Functional Medicine Learn more about our membership models. Application for Functional Primary Care "❋" indicates required fields Step 1 of 8 - Patient Info 0% This application should require 5–10 minutes to complete. Please take your time and answer all questions. Applicant Clarification❋ Who is this application for? For Me For a Dependent Your Contact Information Applicant Name❋ First Last My Email❋ *My* Email Confirm *My* Email Applicant Phone❋ Dependent Information Dependent Name❋ First Last Dependent AgeHow old is your dependent? Dependent Email Option❋ We need a unique email for your dependent, but if you don’t have a second email, we can help you to generate an alias that will still send emails to your email. I’ll provide a second email Please generate a system alias Dependent Email❋ *Dependent* Email Confirm *Dependent* Email Previous Experience Family Connections❋ Are any of your family members active members with Richmond Integrative & Functional Medicine? Yes — I am an active member with RIFM Yes — Someone else in our family is a member. No — No one in our family is an active member. Member Connection❋ First Last Previous Experience❋ Have you previously worked with any of our providers? (Check any that apply) Aaron Hartman Christian Jenski Jodi Caddell No previous experience Health Insurance Insurance Check❋ Do you have a standard health insurance plan? Yes No Membership with RIFM is still possible without health insurance, but would require paying for visits and any labwork out-of-pocket. Payment Intention❋ How would you intend to pay for office visits? I will pay for office visits with cash I am part of a group sharing plan Group SharingPlease include your group sharing plan: Insurance Provider❋ Please select your insurance provider: Aetna Anthem (Blue Cross / Blue Shield) Cigna Humana Medicare Multiplan United Healthcare Other Other Insurance❋Please provide: Insurance Plan❋ Which type of plan do you have? HMO PPO EPO Other RIFM does work with the insurance provider you have provided for most standard HMO & PPO plans. However, because you have listed “other,” for your plan, we cannot pre-qualify you. Please proceed with the rest of the application, but we will need to clarify your insurance. Unfortunately, RIFM does not participate in the insurance network you’ve provided. Membership with RIFM is still possible without health insurance, but would require paying for visits and any labwork out-of-pocket. Payment Follow-Up❋ Would you be able to pay for office visits with cash (i.e. out-of-pocket)? Yes, I will pay for office visits with cash No, I cannot pay for visits without insurance Parent Note Please fill out the following section on behalf of the dependent. Any references to “you” or “your” should be considered your dependent. Health Goals On a scale of 1–5, how happy are you with your present health? TerribleNot so greatNeutralPretty goodExcellent Disatisfaction❋What, specifically, are you unhappy with? 3-6 Month Goals❋What would you like your health to be in 3 months from now? How about 6 months from now Expectations❋If we were to work together what would you expect to achieve from working with us? Potential Barriers Barriers❋ Are there any barriers that might prevent you from completing a functional medicine program or plan (e.g. lifestyle changes or supplement supports)? Children Spouse/Partner Money Self Job Fear Time None of these Barrier Clarification: Children❋Please elaborate: How would your children create a barrier to completing a functional medicine program? Barrier Clarification: Partner❋Please elaborate: How would your spouse or partner create a barrier to completing a functional medicine program? Barrier Clarification: Money❋Please elaborate: How would money create a barrier to completing a functional medicine program? Barrier Clarification: Self❋Please elaborate: How would you create a barrier to completing a functional medicine program? Barrier Clarification: Job❋Please elaborate: How would your job create a barrier to completing a functional medicine program? Barrier Clarification: Fear❋Please elaborate: How would fear create a barrier to completing a functional medicine program? Barrier Clarification: Time❋Please elaborate: How would time create a barrier to completing a functional medicine program? This field is hidden when viewing the form Number of Loves Please enter a number from 5 to 5. 5 Loves❋ What are 5 things you LOVE about your life? Add Remove Δ
