New Patient Orientation Handbook (CCM)

2320 W Commodore Way, Suite 100, Seattle, WA 98199 Phone: (206) 632-4575

welcome

Welcome to our office! Thank you for allowing us to assist you in your healthcare. The following information should help you navigate our office and your treatment. If you have additional questions, please feel free to ask us at any time. We view our relationship with you as a team effort, and communication is essential to our success!

our approach

Dr. Cooper specializes in metabolism, which is the body's way of regulating energy production. The metabolic system affects other important systems throughout the body.

Abnormal metabolism is referred to as metabolic dysfunction, which manifests with symptoms that may vary from person to person. The most common symptoms are unexplained weight gain, reduced satiety, and fatigue. There may also be symptoms such as headaches, anxiety, and irregular periods for women, and increased breast tissue for men. Abnormally low or high blood sugar levels are common.

Problems with glucose and sometimes insulin regulation can eventually lead to diabetes and/ or obesity in genetically susceptible individuals. Metabolic dysfunction frequently disrupts estrogen and testosterone levels in men and women, affecting fertility and reproductive function.

While Dr. Cooper and her physician assistants want to know about your whole health, please maintain an ongoing relationship with your primary care provider for routine appointments and urgent issues that are unrelated to your metabolic concerns.

Through a detailed evaluation we will measure some of the most important biochemical components, hormones, and neurotransmitters that regulate your metabolism and appetite We will focus on health indicators that may be affected by metabolic disruption: blood pressure, cholesterol profiles, glucose and insulin, thyroid, cortisol, reproductive hormones, and general chemistries. This detailed workup, along with your personal health and family history, guides your individualized treatment plan.

By emphasizing medical treatment where appropriate, with structured non-diet lifestyle guidance, our goal is to help repair glitches in the metabolic feedback loop and restore a sense of ‘nutritional security’ in the brain and body –leading to healthy metabolic function and reduction of diabetes and cardiovascular risk.

No two people are the same and no two treatment processes are the same, even within families. With regard to obesity, some patients are more responsive than others, or begin to respond in shorter time frames than others; however, the vast majority of patients experience significant reductions in disease risk, and the majority of patients’ bodies let go of excess body weight in response to treatment. But as with the underlying problems themselves, the solutions also don’t happen overnight.

Metabolic problems can cause other symptoms, unrelated to obesity, such as overtraining syndrome, infertility, chronic fatigue, and cognitive impairment. At Cooper Center for Metabolism, we identify and treat underlying metabolic causes of these conditions.

Obesity

Obesity is categorized as a disease by the American Heart Association and American Medical Association, who refer to obesity as a "multi-metabolic hormonal disease state." Metabolic dysfunction is usually a chronic medical condition. There's is no magic bullet or diet-and-exercise plan that leads to long-term weight loss for patients with obesity. As with any chronic medical condition, the treatment process is not a quick fix.

During medical treatment, even before excess body weight decreases, most frequently any medical complications such as high cholesterol, high blood pressure, or prediabetes improve. Excess weight may not begin to decrease for a number of months after treatment begins. Occasionally there may be weight gain at the start of treatment, not due to the treatment itself but due to backlash from prior dieting. This rebound weight gain after dieting is familiar to most dieters and medical management can usually minimize this potential issue.

Dr. Cooper will inform you if she believes you are at risk of initial temporary weight gain during the treatment process based on your initial lab results. The majority of our patients do not gain weight during the treatment process, though temporary fluctuations in weight are possible.

SUPPORTING A HEALTHY METABOLISM IS CRITICAL FOR EFFECTIVENESS OF MEDICAL TREATMENT

Sleep: Make sure that you are getting enough rest. Sleep is very important to help produce and reset metabolic hormones. Try to get at least 7.5-8 hours of sleep per night, especially between 11 PM and 5 AM, the critical period for metabolic hormone balance.

Hydration: It is important to maintain good hydration, but avoid overhydrating. Drink about half of your body weight in ounces of water throughout the day. For example, if you weigh 200 pounds, you should drink about 100 ounces of water daily

Avoid drinking too much water with meals because it can interfere with metabolic function and increase medication side effects. Instead, have the bulk of your fluids between meals.

Nutrition: Shift your thinking towards fueling your body rather than depriving it. Eat every 2-4 hours, including balanced meals and snacks. A balanced diet, with foods from all three nutrient groups, includes carbohydrates, proteins, and fats with each meal and with snacks. Chemical food additives and certain food packaging could be a source of potential "obesogens." Avoid foods with unrecognizable ingredients and plastic packaging or BpA lined canned foods. Do not heat food in plastic.

• Carbohydrates: Always include complex carbohydrates and starches, such as whole-grain products, beans, legumes, and starchy vegetables (potatoes with skin). Fruits and vegetables are carbohydrates too (5 combined servings for health daily). Include starchy carbohydrates with every meal. It’s fine to include refined carbohydrates (non-whole grain); however, whole foods offer significant health benefits.

• Proteins: dairy, poultry, fish, meats, beans, tofu, nuts.

• Fats: Include olive oil, flax, nuts, nut butters, butter, avocados. Avoid ‘fake’ fats such as ‘partially-hydrogenated’ oils and trans-fats, which have a detrimental impact on health and metabolism.

Exercise: We do not recommend exercise as a weight management tool, but instead for its benefits to health and vitality. Contrary to popular belief, there may be times when less exercise is actually better for your metabolism. If you are unsure, ask your provider whether exercise is appropriate, based on your workup.

If you exercise, fuel every exercise session properly Please request a 'sports nutrition' handout. If you exercise, please speak to your provider about which heart rate zone ranges to emphasize. As soon as your metabolic function is strong enough, exercise can be introduced for health benefits. Your provider will let you know when you are ready to engage in resistance training or cardio exercise.

Kainoa Pauole-Roth, our exercise physiologist, will provide guidelines that include duration, frequency, and intensity. She will also test your fitness level to provide individualized target heart rate zones, and verify that you are burning carbohydrates effectively. If you develop an athletic goal (i.e. 5K, triathlon, half marathon, etc ), we will integrate a training and sports nutrition approach that supports your health and protects your metabolism. There may be times that your provider recommends that you consider an alternative goal.

EXERCISE TIPS

•Always take 2 recovery days per week to allow your body to recover and regenerate. Most of the benefits of exercise occur during recovery.

•If you exercise an hour or more a day, your body needs more fuel and sleep Fueling should consist of 50 - 60 grams of carbs hourly during exercise, at the beginning of the session. An extra hour of sleep allows your system to repair and regenerate.

• If you have a long history of dieting, focus on strength exercise more than cardio exercise.

•It's ideal to measure your aerobic fitness and heart rate training zones. Our front desk can set up an appointment with our exercise physiologist for our Cardiovascular Risk Reduction Series or Strength Series

•Wait until you’ve eaten a few times to start your exercise for the day, so your body realizes that you are not starving.

GENERAL INFORMATION

Office Hours: Our normal business hours are from 7:30 AM to 5 PM, Monday through Thursday. We are closed Friday, Saturday, and Sunday

Medication List: Please bring a complete and detailed list of all your current medications to every appointment, including medication strength and how often you take them. This list should also include any over-the-counter medications, vitamins, and herbal supplements

Please note: Your provider at Cooper Center for Metabolism cannot fill prescriptions from your other healthcare providers.

Coordination of Care: With your written permission, for the best practice and continuity of care, your provider at Cooper Center for Metabolism will share results of lab tests and recommendations with regard to your metabolic workup with your other physicians. Please complete authorization forms permitting this sharing of information.

Mandatory Portal Fee: As we are a small, specialized clinic, Hello Health's PortalConnect provides a secure mode of communication that meets privacy standards, with the functionality required to provide the most effective healthcare This program carries a subscription fee of $69 per year ($5.75/month) payable to the portal, which covers the software licensing fee. Portal membership is mandatory for all patients under our care.

Routine Concerns: If you have an issue to discuss or are experiencing side effects from a medication that your provider has prescribed, please feel free to contact us via PortalConnect. You may send a message to your provider directly or contact a medical assistant. Keep in mind that medication side effects, such as nausea, tend to be self-limiting and will usually go away within a couple of days. Symptoms that last longer may require dosage adjustments and other strategies. We encourage you to communicate your concerns to your provider.

Urgent Concerns: Dr Cooper is available by pager after hours and only in case of an emergency To use this option, please dial the main office number, 206-632-4575, and follow the prompts to be connected to her emergency pager

Confidentiality Requirements: With the exception of minors under the age of 18, all communication must pertain to your own healthcare only According to standard healthcare policy, we cannot answer any questions that are not related to your own care. Dr Cooper encourages you to invite family members with questions about your treatment to come to your appointments so that they can have their concerns addressed with you at that time. We cannot reply to your emails due to confidentiality concerns, so please use PortalConnect for communication, as it provides an appropriate level of online security.

Prescription Refills: Contact your pharmacy directly for all prescription refills. They will either send a fax or an e-prescribing request to our office. We will directly approve requests as we receive them, as long as you are up-to-date with your recommended treatment plan. Our fax number is 206-632-4576. Please verify that your pharmacy is using the correct fax number, since there is another physician with the same name as Dr. Cooper

Note that Dr. Cooper will only authorize refills for medications that she has prescribed. While we will attempt to return Rx requests within 24 hours, please allow a 48hour turnaround for eRx requests and 72 hours for faxed refill requests. Note that our office is closed on Fridays.

Transferring Rx’s to Mail Order Pharmacies: All you need is your current prescription information on the medication bottle Simply call the mail order pharmacy with that information. They will then contact us with the appropriate form to authorize the prescription. For refill requests at a mail order pharmacy, the pharmacy should fax a refill request to our office. As with prescriptions at your local pharmacy, please allow a 48-hour turnaround time for refill requests.

Sending records to another healthcare provider: With your written permission, your provider will share the results of lab tests, evaluations, and recommendations with your other healthcare providers. Please contact the front desk to complete the appropriate authorization form for release of medical information.

Canceling or changing appointments: If you need to change or cancel an appointment, please contact the front desk. Please note our cancellation policy requires a notice from patients three business days (we are closed Friday) in advance in order to avoid a cancellation charge, which is a full-charge fee. Please see your registration form for our cancellation policy.

Interim Lab Results: If you have lab testing between appointments, please contact us if you have not heard from us with results within one week. Your provider will review the results and notify you about any changes in your treatment plan.

Special Labs: We request that all new patients have an 'AgRP' test, which costs $250 out-of-pocket, payable to Inter Science Institute AgRP is the most important metabolism-blocking neurotransmitter, and this information helps to guide treatment.

Additionally, your provider can order optional extensive metabolic hormone tests which are not covered by insurance. The costs can range from $300 for a single test to $2500 for comprehensive fasting and post-meal hormonal-response tests, and these costs are out-of-pocket. If you are interested in learning more about your metabolism by measuring these additional labs, let us know

The specialty lab we use is Inter Science Institute, based in California, and they have offered our patients wholesale pricing. Patients pay Inter Science Institute directly by check. There is a small fee for shipping, payable to SPM. SPM does not profit by measuring these labs. Usual draw fees apply.

Genetic testing is available and in certain cases may help determine a diagnosis and treatment course. Your provider will inform you if this testing is beneficial.

Read Dr Cooper’s book: The Metabolic Storm: The science of your metabolism and why it's making you FAT and possibly INFERTILE Proceeds from book sales are donated to The Diabesity Institute, a 501(c)3 nonprofit that Dr Cooper founded with a mission to increase access to effective science-based medical care for those suffering from diabesity.

Thank You

As a patient of the Cooper Center for Metabolism, you are part of a bigger effort Your de-identified data contributes to an important scientific evidence base for individualized, targeted treatment. You bring awareness and hope to healthcare providers, scientists, and other patients who suffer from metabolic dysfunction

Dr. Emily Cooper is Board Certified in Family, Sports, and Obesity Medicine. In 2003, she founded Seattle Performance Medicine (SPM) to help individuals reach their health and fitness goals. SPM focuses on disease prevention and wellness, sports nutrition, and exercise physiology. Because fitness relies on energy utilization for powering the body and building its structure, metabolism function is a key determinant in exercise performance.

Cooper Center for Metabolism

It became increasingly clear to Dr. Cooper that improving the function of the metabolic system not only allows athletes to perform better, but it also yields enormous health benefits. The metabolism is a complex system which affects numerous other bodily systems. A healthy metabolism is critical in prevention of type 2 diabetes and obesity, and in reversal of prediabetes. Additional benefits can include reduction of cardiovascular and cancer risks, and potentially prevention of Alzheimer’s disease and other forms of agerelated dementia.

To clinically address the underlying causes of obesity, prediabetes, type 2 diabetes, and infertility, Dr. Cooper opened the Cooper Center for Metabolism (CCM), a state-of-theart facility, in 2015. She and her dedicated staff strive to provide the best care possible.

Diabesity Institute

Fifty percent of adults in the United States suffer from prediabetes or type 2 diabetes, and nearly seventy percent are in the overweight or obese categories. Children are increasingly affected by these diseases. This is the diabesity epidemic.

Though every major medical organization now classifies obesity as a disease, the vital role of the metabolism is not detailed in most medical textbooks. Because of the gap in medical training, it will take time for effective science-based treatment to be readily available.

To increase access to care for those suffering from diabesity, Dr. Cooper founded the Diabesity Institute (DI), a 501(c)3 nonprofit. DI focuses on targeted scientific research and clinical data analyses, community outreach, and education for healthcare professionals. In addition to in-person and radio appearances, Dr. Cooper and some of her patients have participated in over 125 televised segments about metabolism on King 5 local news.

Through DI's groundbreaking efforts, we are working together to end the diabesity epidemic.

CCM Staff Roster

Area

Reception / Front Desk

Sophia Rivero

Ashton Evertz

Medical Assistants

Lab / Phlebotomists

Linda Jensen, MA-R

Miyah Davis, MA-R

Karlee Ervin, MA-R

Cheryl Toenyan, CPT

Hannah Junejo, CPT

Megan Bair, CPT

Medical Providers

Ancillary Providers

Medical Records / Admin

Emily Cooper, MD Kristen Heestand, PA-C

Alisha Boxley, ARNP Daphne Carballo, PA-C

Kainoa Pauole-Roth, MS (Exercise Physiologist)

Jennifer Huddy, MS, RD (Registered Dietitian)

Leah Remsen

Kacie Black

Benjamin Bayer

Chris Clatterbuck

Phone: (206) 632-4575 / Fax: (206) 632-4576 / Secure message: https://portalconnect.net/ Website: www.coopermetabolic.com

NEW PATIENT REGISTRATION

(Copy of Registration form you have filled out online)

Thank you for choosing the Cooper Center for Metabolism. Please complete the form below.

First Name: Last Name:

Date of Birth: _______________

Street Address: ___________________________________

Address Line 2: ___________________________________

City: _____________________ State: _____

Zip Code: __________

Phone Number (Cell): ___________________

Phone Number (Other): ___________________

Email Address: ________________________________

Emergency Contact Information

First Name: ____________________ Last Name:

Phone Number: ___________________

Referred by: ___ Health care provider ___ Friend or family member ___ Athletic trainer, coach, personal trainer ___ Internet search ___ Other

Party responsible for payment: Self ___Parent ___ Other: _____________________

Initials: ______

PAYMENT POLICY ACKNOWLEDGEMENT

(Copy of Acknowledgement form you have filled out online)

1. Payment is due in full at the time of service. We accept major credit cards, checks, and cash

2. You will be billed in full for appointments that are not canceled 3 full business days in advance. (Note: For missed lab appointments without one business day's notice you will be charged a flat fee of $25. Since we are closed on Fridays, Monday labs must be canceled by the previous Thursday.) We require a credit card on file for all patients. This card will be charged for failure to cancel your follow-up appointment 3 business days in advance, or your lab appointment one business day in advance. Your signature below indicates your agreement to this charge being applied for late cancellations and no-shows.

3. To avoid a full appointment fee cancellation charge:

To cancel a Monday appointment notify us by the prior Tuesday

To cancel a Tuesday appointment notify us by the prior Wednesday

To cancel a Wednesday appointment notify us by the prior Thursday

To cancel a Thursday appointment notify us by the prior Monday

If you have missed your lab appointment, we do not automatically cancel your follow-up appointments. You are still expected to show up for your follow-up, and if you plan to cancel that appointment, it is solely your responsibility to cancel the appointment.

4. Cooper Center for Metabolism is not a participating provider (non-network), and we do not bill insurance. It is your responsibility to check with your insurance carrier about coverage for non-network providers. We provide a claim form for you to submit to your insurer for reimbursement. We do not guarantee reimbursement for charges incurred at Cooper Center for Metabolism. Please be aware of your particular plan’s requirements for out-of-network services.

5. We charge a fee for obtaining and processing blood/urine specimens. This fee is separate from the lab fee. The lab will bill your insurance directly for the testing run on the specimen. Your insurance carrier will notify you of any remaining balance. Some insurers require a specific lab or in-network provider to order and process labs. If you are unaware of your coverage for lab testing, please check with your insurance provider to verify your coverage.

Initials: ______

I acknowledge that I have read this document in its entirety. I understand and accept the policy regarding insurance coverage, cancellation policies, and payment responsibility as explained herein by Cooper Center for Metabolism. I permit CCM to charge my credit card on file for any missed appointments without required notice as described above.

Signature of Patient or Legal Guardian Date

Print Name

Pricing Sheet (as of April 3, 2023)

Emily Cooper, MD

Kristen Heestand, PA-C; Daphne Carballo, PA-C; Alisha Boxley, ARNP

Kainoa Pauole-Roth, Exercise Physiologist

Jennifer Huddy, Registered Dietitian

Mandatory Portal Fee:

To ensure a secure mode of communication that meets privacy standards, with the functionality required to provide the most effective healthcare, we require registration in Hello Health's PortalConnect.

The program carries a subscription fee of $69 per year ($5.75 / month) payable through the portal, which covers the software licensing fee.

Portal membership is mandatory for all patients under our care.

Thank you,

Emily Cooper, MD

Kristen Heestand, PA-C

AgRP Testing Purpose and Cost:

Agouti-related peptide (AgRP) is an important neurotransmitter produced primarily by the brain (hypothalamus). Excess AgRP blocks normal metabolic function and influences body weight, reproductive hormones, thyroid hormones, insulin response, and appetite. We recommend AgRP baseline testing for all patients, although it is not covered by insurance.

If you are having an AgRP test, please leave a check with the lab personnel for $250.00 payable to ISI (Inter Science Institute) before leaving today. If you do not have a check with you, please mail us a check as soon as possible. Please note the check may not be cashed promptly by Inter Science Institute; it is cashed after the test is completed, which may take up to 60 days.

We must ship the lab sample with your check to the reference lab in California within 30 days. Samples older than 30 days will be discarded as the testing accuracy is no longer reliable.

Thank you, Emily

Cooper, MD

Kristen Heestand, PA-C

Offsite Lab Protocol:

Most of the labs we order are non-customary and require a specific processing method. Therefore, we strongly encourage you to have blood drawn for interim and routine labs here in our office in all possible cases. This minimizes errors, lessens the chance that you will need to repeat labs, and ensures that we receive results in a timely manner prior to your appointment.

We understand that there may be times when it simply isn't possible for you to complete labs here. In these cases, to avoid any delays, we ask that you adhere to the following protocol.

If you live out-of-state, please follow this protocol regardless of which lab you visit (Quest, LabCorp, or another). If you live in-state, please follow this protocol if you visit a lab other than Quest or LabCorp (we only receive results from Quest and LabCorp electronically).

1. You are responsible for bringing a copy of your lab slip to the offsite lab you are visiting.

2. After completing your labs, please send a message to Medical Records through PortalConnect (Hello Health), confirming that you have completed your labs.

3.Because we do not routinely receive offsite results, it is necessary for you to then upload your lab results to your Hello Health library as soon as possible prior to your appointment.

If you have any questions or concerns, do not hesitate to contact your provider.

Thank you,

Emily Cooper, MD

Kristen Heestand, PA-C

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our Pledge to Protect Your Privacy

At Seattle Performance Medicine/Cooper Center for Metabolism (SPM/CCM), we know that medical information about you is personal, and we are committed to protecting the privacy of your information. As a patient of SPM/CCM, the care and treatment you receive is notated in a medical record. So that we can best meet your medical needs, we must share your medical record with other healthcare providers involved in your care. We also share your information only to the extent necessary to conduct our business operations and to comply with the laws that govern healthcare. We will not use or disclose your information for any other purpose without your permission.

We are required by law to:

• Make sure your medical information is kept private

• Give you this Notice of our legal duties and privacy practices with respect to medical information about you and

• Follow the terms of the Notice that is currently in effect.

We have a responsibility to safeguard the privacy and integrity of your records. This Notice explains our privacy practices and your rights regarding your medical information.

Who Will Follow This Notice

The following parties share the commitment to protect your privacy and will comply with this Notice:

• Any healthcare professional authorized to enter information into your medical records

• All departments of SPM/CCM

• All employees, trainees, students, contractors, and practitioners of SPM/CCM

Your Rights Regarding Medical Information About You

You1 have the following rights regarding your medical information:

Right to Inspect and Obtain a Copy of Your Medical Record: You have the right to inspect and obtain a copy of the medical records that SPM/ CCM uses to make decisions about you and your treatment, subject to certain limited exceptions. This information includes your medical and billing records, but may not include some mental health information. We reserve the right to charge a fee to cover the cost of providing records to you.

Right to Request a Correction or Addendum to Your Medical Record:

• Correction: If you believe that medical information SPM/CCM has on file about you is incorrect or incomplete, you may ask us to correct the medical information in your records. If your medical information is accurate and complete, or if the information was not created by SPM/CCM, we may deny your request; however, if we deny any part of your request,

1 “You” in this Notice means an SPM/CCM patient or, if applicable, the patient’s personal representative. A personal representative is any person authorized to act on behalf of the patient with respect to his or her care. For example, a personal representative may include the parent or guardian of a minor (unless the minor has the authority under Washington law to act on his or her own behalf), the guardian or conservator of an adult patient, or the person authorized to act on behalf of a deceased patient.

You may ask for a copy of our current Privacy Notice at any time from our Front Desk. We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice will be available upon request from our Front Desk.

Effective November 11, 2019

we will provide you with a written explanation of our reasons for doing so.

• Addendum: In addition, an adult patient of SPM/CCM who believes that an item or statement in his or her medical record is incorrect or incomplete has the right to provide SPM/CCM with a written addendum to his or her record.

Right to an Accounting of SPM/CCM Disclosures of Your Medical Information: You have the right to request an “accounting of disclosures,” which is a list describing how we have shared your medical information with outside parties. This accounting is a list of the disclosures we made of your medical information for purposes other than treatment, payment, and healthcare operations, as those functions are described below in the Section of this Notice entitled, “How We May Use and Disclose Medical Information About You.”

Right to Request Restrictions: You have the right to request restrictions on certain uses or disclosures of your medical information. For example, you may request that we do not disclose information about a procedure you have undergone. Requests for restrictions must be in writing; the appropriate instructions and forms are available at the Front Desk. We are not required to agree to your requested restriction. However, if we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or to comply with the law. If we cannot accept your request, we will explain to you in writing why we cannot do so.

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work, rather than your home. You may request confidential communications during your initial appointment with SPM/CCM or at any other time during your treatment. We will not ask you the reason for your request, and we will use our best efforts to accommodate all reasonable requests.

Right to a Copy of this Notice Upon Request: You have the right to a copy of this Notice. It is available from our Front Desk.

Contact Information: To obtain information about how to request a copy of your medical or billing records, receive an accounting of disclosures, or correct or add an addendum to your medical information, please contact SPM/CCM's Front Desk at (206) 632-4575.

How We May Use and Disclose Medical Information About You

The following sections describe different ways that we may use and disclose your medical information. To respect your privacy, we will try to limit the amount of information that we use or disclose to that which is the “minimum necessary” to accomplish the purpose of the use or disclosure. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the following categories:

For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, physician assistants, nurses, technicians, medical students, or other SPM/CCM personnel who are involved in your care.

For Prior Approval: We may tell your insurance about a medication you are going to receive to obtain prior approval or to determine whether your plan will cover the medication.

For Health Care Operations: We may use and disclose medical information about you for the functions necessary to run SPM/CCM, and assure that all of our patients receive quality care. We may also share your medical information with affiliated healthcare providers so that they may jointly perform certain

You may ask for a copy of our current Privacy Notice at any time from our Front Desk. We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice will be available upon request from our Front Desk.

Effective November 11, 2019

business operations along with SPM/CCM For example, we may use medical information to review our treatment and services and evaluate the performance of our staff in caring for you. We maycombine medical information about many of our patients to decide what additional services SPM/CCM might offer, what services are not needed, and whether certain new treatments are effective. We mayshare information with doctors, physician assistants, nurses, technicians, medical students, and other personnel for quality assurance and educational purposes. We mayalso compare the medical information we have with information from other practices to see where we can make improvements in the care and services we offer.

Business Associates: SPM/CCM contracts with outside companies that perform business services for us, such as management consultants, quality assurance reviewers, accountants, or attorneys. In certain circumstances, we mayneed to share your medical information with a business associate or subcontractor to perform a service on our behalf. SPM/CCM will limit the disclosure of your information to a business associate to the amount of information that is the “minimum necessary” for the company to perform services for SPM/CCM. In addition, where appropriate, we will have a written contract in place with the business associate/subcontractor requiring it to protect the privacy of your medical information.

Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or care at SPM/CCM

Treatment Alternatives: We mayuse and disclose medical information to tell you about or recommend possible treatment options or alternatives that maybe of interest to you.

Health-Related Benefits and Services: We mayuse and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

Individuals Involved in Your Care: We maydisclose medical information about you to an organization assisting in a disaster relief effort (such as the Red Cross) so that your family can be notified about your condition, status, and location.

Research: SPM/CCM maybe involved in studies that may involve your de-identified data regarding current care or that involve reviews of your medical history. We may share de-identified medical information with scientists or researchers in an effort to analyze treatment outcomes and improve access to effective treatment. Any individualized case reports for publication require written consent.

To Prevent a Serious Threat to Health or Safety: We mayuse and disclose certain information about you when necessary to prevent a serious threat to your health and safety or the health and safety of others. However, any such disclosure will only be to someone able to help prevent the threat, such as law enforcement, or a potential victim. For example, we may need to disclose information to police when a patient reveals that he or she has participated in a violent crime.

Additional Situations that DO NOT Require Us to Obtain Your Authorization

Public Health Activities: We maydisclose medical information about you for public health activities. These activities include, but are not limited to, the following:

• To prevent or control disease, injury, or disability

• To report births or deaths

• To report abuse or neglect of children, elders, and dependent adults

• To report reactions to medications or problems with products

• To notify you of the recall of products you may be using

You may ask for a copy of our current Privacy Notice at any time from our Front Desk. We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice will be available upon request from our Front Desk.

• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition

• To notify the appropriate government authority if we believe you have been the victim of abuse, neglect, or domestic violence; we will only make this disclosure when required or authorized by law.

Health Oversight Activities: We may disclose medical information to a health oversight agency, such as the Washington Department of Health, for activities authorized by law. These oversight activities include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order We may also disclose medical information about you in response to a subpoena, legally enforceable discovery request, or other lawful process by someone else involved in the dispute.

Law Enforcement: We may release medical information if asked to do so by law enforcement officials in the following limited circumstances:

• In response to a court order, subpoena, warrant, summons, or similar process

• To identify or locate a suspect, fugitive, material witness, or missing person

• Information about the victim of a crime if, under certain limited circumstances, the victim is unable to consent

• Information about a death we believe may be the result of criminal conduct

• Information about criminal conduct at SPM/CCM, and

• In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.

Coroners, Medical Examiners, and Funeral Directors: We may release medical information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We may also release medical information about patients of SPM/CCM to funeral directors as necessary to carry out their duties with respect to the deceased.

Organ and Tissue Donation: We may release medical information to organizations that handle organ, eye, or tissue procurement or transplantation, as necessary to facilitate organ or tissue donation. The procurement or transplantation organization needs your authorization for any actual donation.

Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military-command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.

National Security and Intelligence Activities: Upon receipt of a request, we may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law We will only provide this information after the Privacy Office has verified the validity of the request and reviewed and approved our response.

Other Uses or Disclosures Required by Law: We will also disclose medical information about you when required to do so by federal, state, or local laws that are not specifically mentioned in this Notice.

Changes to This Notice

We reserve the right to change our privacy practices and update this Notice accordingly We reserve the right to make the revised or changed Notice effective for medical information we already have about you

You may ask for a copy of our current Privacy Notice at any time from our Front Desk. We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice will be available upon request from our Front Desk.

Effective November 11, 2019

as well as any information we receive in the future. The most current Notice is available at the SPM/ CCM Front Desk. The Notice contains the effective date on the first page, in the top right-hand corner.

Comments or Complaints

We welcome your comments about our Notice and our privacy practices. If you believe your privacy rights have been violated, you may file a complaint with SPM/CCM or with the Secretary of the Department of Health and Human Services (200 Independence Avenue, S.W., Washington DC, 20201). To register a comment or file a complaint with SPM/CCM, please contact:

Privacy Office

Seattle Performance Medicine/Cooper Center for Metabolism

2320 W Commodore Way Suite 100

Seattle WA 98199

Phone: (206) 632-4575

Fax: (206) 632-4576

Please be assured that no one will retaliate or take action against you for filing a complaint.

Other Uses of Medical Information

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the activities covered by the authorization, except if we have already acted in reliance of your permission. We are unable to take back any disclosures we have already made with your authorization, and we are required to retain our records of the care that we provided to you.

You may ask for a copy of our current Privacy Notice at any time from our Front Desk. We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice will be available upon request from our Front Desk.

ACKNOWLEDGMENT: RECEIPT OF NOTICE OF PRIVACY PRACTICES

I have received a copy of Seattle Performance Medicine’s Notice of Privacy Practices effective November 11, 2019

Name (please print): __________________________________

Signature: ___________________________________

Date: _____________________________

I am a parent or legal guardian of ______________________ (patient name). I have received a copy of SPM/CCM Notice of Privacy Practices effective November 11, 2019

Name (please print): __________________________________ Legal Guardian

Relationship to Patient: Parent

Signature: ___________________________________

Date: _____________________________

If the individual or parent/legal guardian did not sign above, staff must document when and how the Notice was given to the individual, why the acknowledgment could not be obtained, and the efforts that were made to obtain it.

Notice of Privacy Practices effective November 11, 2019 given to individual on

(date).

Reason individual or parent/legal guardian did not sign this form: Did not want to

I,_________________________________, authorize Cooper Center for Metabolism and Performance Medicine (CCM/SPM) to disclose protected to the individual(s) indicated below. is limited to the status of any upcoming appointments and payments due, unless otherwise indicated, and can be obtained from any employee of CCM/SPM.

To protect your a password will be required to confirm the of approved individual(s).

Password

In add on to disclosing protected health informa on I hereby grant the above individuals the ability to: Schedule, reschedule and otherwise alter my appointments

I understand that I remain liable for any late or no show fees incurred regardless of who scheduled or changed the appointment

Access protected health inform n including my complete medical records otherwise considered and protected by HIPAA

Pick-up samples on my behalf

Discuss and resolve outstanding payment issues

CCM and SPM are hereby released from all legal responsibility or liability for the release of the above I understand that my records are protected under the Federal and State and cannot be disclosed without my consent unless otherwise provided for in the I understand that I have the right to withdraw this at any except for already taken, and that such must be in Further, I understand that this will remain for two years from the signed date and I may then renew bi-annually.

SEATTLE PERFORMANCE MEDICINE

Optimize the system, maximize performance

Name: Date of Birth:

� Cooper Center for Metabolism

Specializing in metabolic causes of obesity, diabetes and infertility

authorization to release medical information

Address: --------------------------------------D From □ To

Name:

Address:

Phone: Fax: -------------------

□ From □ To

Seattle Performance Medicine

Cooper Center for Metabolism

2320 W Commodore Way

Seattle, WA 98199

Phone: 206-632-4575

Fax: 206-632-4576

Records to Include:

D All records retained from this facility

D Chart notes

D Laboratory results

D Other information:

Disclosure of Sensitive information; Iunderstandthatmyhealthrecordmaycontainsensitiveinformationrelatingtomycondition(s). Thisincludes,butisnotlimitedto,informationpertainingtosexuallytransmitteddisease,humanimmunodeficiencyvirus(HIV), acquiredimmunodeficiencysyndrome(AIDS),behavioralormentalhealthservices,andtreatmentforalcoholanddrugabuse.

Bychecking this box, I choosetoEXCLUDEtheabovetypesofinformationfromthisdisclosure.

NOTICETO PERSON(S) and/orORGANIZATIONSWHORECEIVEMEDICALINFORMATION: REDISCLOSUREPROHIBITED. Itisanexpectationthatyouwillrecognizethattheinformationdisclosedtoyouisprivateinformationandthatre-disclosurewithout additionalpatientconsent(unlessrequiredbylaw)isprohibited.

Seattle Performance Medicine isherebyreleasedfromalllegalresponsibilityorliabilityfortherelease oftheabovementioned information Iunderstandthat myrecordsare protectedunder theFederalandState confidentialityregulationsandcannot bedisclosedwithout mywrittenconsentunlessotherwiseprovidedforintheregulations. IunderstandthatIhavetherighttowithdraw thisauthorizationatanytime, exceptforactionalreadytaken, andthatsuchrevocationmustbeinwriting. Further, Iunderstandthat thisauthorizationwillremainactiveuntilIprovidewrittenterminationofthisagreement.

Signature: Date: _____________ D Patient D Parent D Guardian

Section 4507 of the 1997 Balanced Budget Act allows a physician or practitioner to enter a private contract with a Medicare beneficiary.

I, Emily Cooper (Provider NPI 1316142862), and I, Kristen Heestand (Provider NPI 1952851651) have not been excluded from Medicare under sections 1128, 1156, or 1892 of the Social Security Act

I ______________________________________ (the Medicare beneficiary) or my legal representative accept full responsibility for payment of charges for all services furnished by Seattle Performance Medicine.

I ______________________________________ (the Medicare beneficiary) or my legal representative understand that Medicare limits do not apply to what Emily Cooper, Kristen Heestand, and Cooper Center for Metabolism/Seattle Performance Medicine may charge for items or services furnished.

I ___________________ (the Medicare beneficiary) or my legal representative agree not to submit a claim to Medicare or to ask Cooper Center for Metabolism/Seattle Performance Medicine to submit a claim to Medicare.

I ______________________________________ (the Medicare beneficiary) or my legal representative understand that Medicare payment will not be made for any items or services furnished by Cooper Center for Metabolism/Seattle Performance Medicine that might otherwise have been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.

I ______________________________________ (the Medicare beneficiary) or my legal representative enter into this contract with the knowledge that I have the right to obtain Medicare-covered items and services from a physician and/or practitioner who has not optedout of Medicare, and I am not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not optedout.

The expected or known effective date and expected or known expiration date of the opt-out period is May 15, 2017 and April 30, 2019 (automatically renews every two years thereafter)

I ______________________________________ (the Medicare beneficiary) or my legal representative understand that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.

This contract cannot be entered into by me, (the Medicare beneficiary), or by my legal representative during a time when I, (the Medicare beneficiary), require emergency care services or urgent care services. (However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 3044.28 of the Medicare Carriers Manual ) I, (the Medicare beneficiary), or my legal representative will receive or have received a copy (a photocopy is permissible) of this contract, before items or services are furnished to me under the terms of this contract.

Medicare Private Contract

I, Emily Cooper, and I, Kristen Heestand, and Cooper Center for Metabolism/Seattle Performance Medicine, will retain the original contract (original signatures of both parties required) for the duration of the opt-out period.

I, Emily Cooper, and I, Kristen Heestand, and Cooper Center for Metabolism/Seattle Performance Medicine, will supply CMS with a copy of this contract upon request.

I, Emily Cooper, and I, Kristen Heestand, and Cooper Center for Metabolism/Seattle Performance Medicine, understand that the current private contract remains in effect for two years. If I again opt-out of Medicare, I will expediently complete a new contract for each Medicare beneficiary and will expediently submit the appropriate affidavit(s) to all local Medicare carriers.

Patient’s Signature: _______________________________ ___

Patient's Name:

Date:

Provider’s NPI: 1316142862

Provider’s Signature: __________________________________ Emily Cooper

Provider’s NPI: 1952851651

Provider’s Signature: __ Kristen Heestand

Date: _

Date: _

Consultation Protocol for Out-of-State Patients

As of January 10th 2022, all patients must be physically present in Washington State at the time of their appointments with providers (whether in-person or via telemedicine). This policy applies to all patients, even those who reside in Washington State and happen to be physically outside WA at the time of their appointment.

Thank you!

SPM / CCM Staff

Covid-19 Policies and Protocols

As of December 2021, the following policies are in effect while in our clinic to protect all patients and staff:

• Proof of full vaccination is required of all age-eligible patients, staff, and visitors who are onsite.

• All patients and visitors must wear well-fitting masks (in place of loose cloth or surgical masks) at all times while onsite, except when eating or drinking.

• No one may accompany a patient in the clinic unless they are a child or otherwise require assistance.

• No more than 2 people should use the kitchen at a time.

• No more than 8 people should use the conference room at a time.

• All patients and visitors should remain as socially distanced as possible.

• Our staff cleans and disinfects all common areas in the clinic daily.

o We also deploy portable high-filtration air filters, highfiltration HVAC, and UV disinfection around the clinic

• All provider appointments will be conducted via telemedicine or phone until further notice.

CCM Protocol Checklist

PortalConnect

AgRP

Notice of Privacy Practices

Authorization to Disclose PHI

Authorization to Release Medical Information

Medicare Private Contract

Protocol for Out-of-State Patients

Acknowledgment: My signature below indicates that CCM/SPM staff reviewed the above mentioned policy forms with me, and answered my questions satisfactorily. Signature