Please help us provide you with a complete evaluation by taking the time to fill out this intake carefully. All of your answers will be held in strict confidence unless otherwise specified. If there is anything you wish to bring to our attention that is not asked on this form, please note it in the comments section. Please submit all paperwork at least a day prior to your scheduled appointment. We appreciate your cooperation.

On the following lists, please check all of the symptoms that you are currently experiencing.

Insurance

Dr. Susan L. Marra does not participate with any HMO, PPO, POS, Medicare, Medicaid or any other insurance plans. Her office does not submit insurance claims nor is assignment accepted. All services rendered are fee for service. You will receive an insurance compliant super-bill to submit to your insurance company if you so desire. It is the patient's responsibility to contact their insurance company to determine their coverage and limitations in regards to out of network Naturopathic medical services.

Payment

Payment is expected at the time of service. We accept cash, check, Visa or Mastercard. Checks should be made payable to: Dr. Susan L. Marra. Please refer to the Financial Responsibility & Fee Schedule for more information.

Cancellation/Lateness/No-Show

Please be on time for all appointments (Office/Video/Phone). If you have a Video or Phone appointment, Dr. Marra will call you at your scheduled time. Please also make sure that you're in an area that has proper phone reception.

INITIAL NEW PATIENT APPOINTMENT: Appointment must be cancelled at least 3 business days prior to the scheduled date or the FULL AMOUNT WILL BE CHARGED.
ESTABLISHED PATIENTS: Appointment must be cancelled at least 2 business days prior to the scheduled follow-up or THE FULL AMOUNT WILL BE CHARGED.

The same applies if you do not show up for your appointment or you cannot complete your consent forms and return them to the office prior to your appointment. If you are running late, please call the office at (206) 299-2676 to notify us, and we will determine if you are able to keep or reschedule your appointment. This allows Dr. Marra to better provide the care that is required, as well as ensures fairness for everyone.

PATIENTS WHO SCHEDULE AND FAIL TO KEEP THREE APPOINTMENTS IN THE SPAN OF ONE YEAR WILL BE DISMISSED FROM THE PRACTICE. This is to ensure fairness to both the physician, and other patients needing to be seen by Dr. Marra. Please be mindful of the needs of others.

Prescriptions

Prescriptions will be filled for 2 months ONLY at a time. No other refills will be dispensed until a proper follow up visit (with routine labs) has occurred. This is to protect both you and Dr. Marra, as this is also a medical legal issue. If you require a prescription refill, please call your pharmacy requesting a refill. Your pharmacy will fax us. Please allow 24-48 hours for refills to be completed. Please plan appropriately if you are leaving on vacation, or live out of town.

Appointments

For ALL subsequent visits, patients are required to have mandatory routine labs done at least 48 hours before EVERY appointment. These routine labs are not lab specific or require fasting. All patients are required during their Video or Phone appointments to provide Dr. Marra with their vitals (Blood Pressure, Pulse, Temperature and Weight).

Phone Calls

In an effort to conserve time and energy when calling the office, PLEASE LEAVE YOUR NAME, PHONE NUMBER (with area code) and A BRIEF MESSAGE. All calls will be returned at the end of each business day. Please be mindful when calling the office and Dr. Marra's personal cell phone. Dr. Marra's personal cell phone is for EMERGENCIES ONLY. ALL NON URGENT texts/phone calls to Dr. Marra's cell phone will incur a fee. We are a highly specialized practice dealing primarily with tick-borne diseases. You must have a primary care doctor. We are not a primary care practice, and encourage you to call your primary care doctor or specialist for needs outside of your treatment. For all non-urgent or non-related treatment questions, please make a list for Dr. Marra at your visits. Please do not email our office with questions as they will not be answered. It is a HIPAA violation.

Financial Responsibility & Fee Schedule

We require this form to be fully completed and signed by all patients prior to their initial consultation. We greatly appreciate your cooperation, as this is a fee for service medical specialty practice. Please contact the office with any questions that you may have regarding any of the following issues:

Financial Responsibility

Dr. Susan L. Marra is not affiliated with any insurance policies or companies, including HMO, PPO, POS, Medicare, Medicaid or any other insurance plans. Dr. Marra's office does not submit insurance claims nor is assignment accepted. If you have questions regarding insurance, we ask that you call your insurance carrier specific to your plan. All services rendered are fee for service and payment is expected at the time of the service. You will receive an insurance compliant receipt to submit to your insurance company at every appointment, whether it be in the office or telephone. By signing below, you understand that you are personally responsible for any and all fees incurred with the consultation and/or medical services rendered by Dr. Marra. These may also include: supplies, supplements, and other services provided. Please note that blood draws and testing will be billed to you separately by the laboratory that performed the blood draw and any specific tests ordered by Dr. Marra.

Scheduling & Appointments

Please be on time for all of your appointments (Office/Phone/Video). Patients are not permitted to go longer than 8 weeks without a follow-up office appointment or phone consult. If you have a phone appointment, Dr. Marra will call you at the scheduled time. Routine labs are required to be completed at least 48 hours prior to your scheduled appointment. Failure to do so will result in a $25.00 fee that will be applied to your appointment fee. A copy of your credit card will be required as a patient, and will be kept on file. This credit card will be charged in the event of failure to follow any of the office policies listed below or on the office guidelines.

Cancellations/Lateness/No-Show

PATIENT APPOINTMENTS: ALL appointments must be cancelled at least 3 business days prior to the scheduled date or the full appointment cost will be charged. We are open Mon, Tues, Thur, Fri. Please give us three of our business days of notice. We are not open Wednesdays; please take that into consideration when cancelling.

The same applies if you do not show up for your appointment or you cannot complete your consent forms and return them to the office one week prior to your appointment. If you are running late, please call the office at (206) 299-2676 to notify us, and we will determine if you are able to keep or reschedule your appointment. This allows Dr. Marra to better provide the care that is required, as well as ensures fairness for everyone.

PATIENTS WHO SCHEDULE AND FAIL TO KEEP THREE APPOINTMENTS IN THE SPAN OF ONE YEAR WILL BE DISMISSED FROM THE PRACTICE. This is to ensure fairness to both the physician, and other patients needing to be seen by Dr. Marra. Please be mindful of the needs of others.

Phone Calls & Texts

We do our best to return all calls made to the office, however, if you have questions that can be answered at your appointments, we would prefer that you write a list of your questions and Dr. Marra will address them at your appointments. We are not a primary care practice and encourage you to call your primary care doctor or specialist for all concerns and questions related to treatments and problems outside of your protocol. Please refer to the fee schedule. Please call the office at (206) 299-2676 for assistance.

Fee Schedule

(Please initial below stating that you understand and agree)

A deposit of $400 is required at the time of scheduling for all new patient appointments. This amount will be applied as a credit towards the total cost of the initial visit.

Office Guidelines

Office Visits

PLEASE BE ON TIME TO YOUR APPOINTMENT WITH YOUR PAPERWORK FILLED OUT COMPLETELY BEFORE YOU ARRIVE TO THE OFFICE. THIS IS TO ENSURE FAIRNESS TO OTHER PATIENTS WHO COME FROM FAR AWAY AND MAY NEED TO CATCH FLIGHTS, AS WELL AS TO DR. MARRA. EVERYONE'S TIME IS VALUABLE, SO PLEASE SHOW CONSIDERATION. MINDFULNESS OF THE NEEDS OF OTHERS IS A BASIC PRINCIPLE OF THIS OFFICE.

1. If someone can accompany you to your office visit, we highly recommend this so both of you can digest the information received. Otherwise, it can be and feel overwhelming.
2. Please bring a notebook to your office visits to write down answers to any questions that you may have.
3. Please bring a list of your questions with you to your office visits. If you have pictures and/or labs, please print those out ahead of time. We find this helps both you and Dr. Marra to be organized and thoughtful with regards to formulating your treatment plan.
4. The first office visit will entail a detailed history taking, physical exam, and suggestions to necessary laboratory work. All lab work needs to be done at a LabCorp facility. LabCorp has multiple locations, please visit their website for more information at www.labcorp.com. About 4 weeks after you have been drawn for your labs, a second visit will occur. Specialty kits are generally done at home, but we will advise you on how to properly collect for those during your first visit.
5. The second office visit is a detailed review of your laboratory work. Discussion of a treatment plan will occur and be implemented at this time. Please do not call the office inquiring about your labs before your second visit. Labs will thoroughly be discussed and reviewed with you by Dr. Marra at your second visit.
6. Roughly 4-6 weeks later, depending on the patient and the severity of the disease, in question, patients will return for another office visit to review progress. Subsequent office visits will then be determined based on the individual needs of each patient.
7. Please refrain from wearing any scented products into the office as patients are often chemically sensitive and simply cannot tolerate odors. Please also be bathed and clean before your visit.

Office Rules

1. Please be on time for all appointments (Office/Video/Phone). If you have a Phone appointment, Dr. Marra will call you at your scheduled time.
2. PATIENTS WILL NOT BE PERMITTED TO GO LONGER THAN 8 WEEKS WITHOUT A FOLLOW UP APPOINTMENT (Office/Video/Phone). It is important in the healing process to check in with Dr. Marra fairly regularly. This is also a medical legal issue that we enforce in the practice. Patients who schedule and fail to keep three appointments, or give less than 2 business days notice to cancel their appointment in the span of one year will be dismissed from the practice.
3. In an effort to conserve time and energy when calling the office, PLEASE LEAVE YOUR NAME, PHONE NUMBER (with area code) and A BRIEF MESSAGE. All calls will be returned by the end of each business day, or latest next business day. Please be mindful when calling the office and Dr. Marra's personal cell phone. Dr. Marra's personal cell phone is for EMERGENCIES ONLY. ALL NON-URGENT phone calls/texts to Dr. Marra's cell phone will incur a fee. We are a highly specialized practice dealing primarily with tick-borne illness. You must have a primary care doctor. We are not a primary care practice, and encourage you to call your primary care doctor or specialists for needs outside of your treatment. For all non-urgent or non-related treatment questions, please make a list for Dr. Marra at your visits. Please do not email our office with questions as they will not be answered. It is a HIPAA violation.
4. Prescriptions will be filled for 2 months ONLY at a time. No other refills will be dispensed until a proper follow up visit has occurred. This is to protect both you and Dr. Marra, as this is also a medical legal issue. If you require a prescription refill, please call your pharmacy requesting a refill. Your pharmacy will fax us. Please allow 24-48 hours for refills to be completed. Please plan appropriately if you are leaving on vacation, or live out of town.
5. Dr. Susan L. Marra does not participate with any HMO, PPO, POS, Medicare, Medicaid or any other insurance plans. Her office does not submit insurance claims nor is assignment accepted. All services rendered are fee for service. You will receive an insurance compliant super-bill to submit to your insurance company if you so desire. It is the patient's responsibility to contact their insurance company to determine what their coverage and limitations are in regards to Naturopathic medicine and out of network medical services.
6. For ALL subsequent visits, we require patients to do mandatory routine labs 2-3 days before EVERY appointment. These routine labs do not require you to fast. This helps Dr. Marra maintain good medical practice. If you do not have labs done before every appointment, a small fee will incur due to the follow-up that may be required by Dr. Marra after your scheduled appointment. Please refer to the fee schedule.
7. Supplements are available in the office to patients only. If you wish to order supplements, please call us and we will do our best to fulfill orders within a reasonable amount of time. Shipping is available through USPS.
8. We strongly recommend that patients avoid WHEAT, DAIRY and SUGAR at all costs, as these are generally inflammatory foods. The idea is to "alkalize" the body for maximal healing to take place. If you are interested, please check out Dr. Marra's website under, "Recommended Reading".

PLEASE DO NOT PHONE THE OFFICE FOR YOUR TEST RESULTS, AS THEY WILL NOT BE GIVEN TO YOU OVER THE PHONE OR MAILED TO YOU DIRECTLY, UNLESS PREVIOUSLY DISCUSSED WITH DR. MARRA. ALL TEST RESULTS ARE TO BE REVIEWED WITH DR. MARRA AND COPIES WILL BE GIVEN TO YOU OR MAILED TO YOU AFTER AN APPOINTMENT WITH DR. MARRA.

IF THERE ARE ANY LABORATORY VALUES THAT NEED IMMEDIATE ATTENTION, DR. MARRA WILL TELEPHONE YOU.

Adherence to these guidelines is both appreciated and enforced in the office. We are truly interested in your well-being and through Dr. Marra's personal and clinical experience, the above rules actually optimize your healing experience.

HIPAA Consent Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed, and how you can obtain access to this information. Please review this document carefully.
State and Federal laws require physicians to maintain the privacy of your health information and to inform you about privacy practices by providing you with this notice.

Uses and Disclosures of Health Information

This notice will remain in effect until it is amended or replaced by the physician under lawful guidelines. It is the physician's right to change the privacy practices provided law permits the changes. Before making a significant change, this notice will be amended to reflect the changes and the office will make the notice available upon request. We reserve the right to make any changes in the office privacy practices and the new terms of the notice effective for all health information maintained, created and/or received by the office before the date changes were made.

You may request a copy of this Privacy Policy notice at any time by contacting the office or by downloading it off of our website at www.drsusanmarra.com. Information on how to contact us can be found at the top of this notice. We will keep your health information confidential using it ONLY for the following purposes:

Treatment:
We may use your health information to provide you with our professional services. We have established "minimum necessary to know" standards that limit staff member's access to your health information. Everyone on the staff is required to sign a confidentiality statement.

Disclosure:
We may disclose and/or share your health information with other healthcare professionals who provide treatment and/or services to you. These professionals will have a privacy and confidentiality policy similar to this one. Health information about you may also be disclosed to your family, friends and/or other persons you choose to involve in your care, only if you agree that we may do so.

Emergencies:
We may use or disclose your health information to notify or assist in the notification of a family member or anyone responsible for your care, in case of an emergency involving your care, your location, your general condition or death. If at all possible, we will provide you with an opportunity to object to this use or disclosure. Under emergency conditions, or if you are incapacitated, we will use our professional judgment to disclose only that information that directly applies and is relevant to your care. We will also use our professional judgment to make reasonable inferences of your best interest by allowing someone to pick up filled prescriptions, x-rays, or other similar forms of health information and/or supplies unless you have advised otherwise.

Healthcare Operations:
We will use and disclose your health information to keep the practice operable. Examples of personnel who may have access to this information include: but are not limited to the medical records staff, outside health or management reviewers and individuals performing similar duties.

Public Health Responsibilities:
We will disclose your healthcare information to report problems with products, reactions to medications, product recalls, and disease/infection exposure and to prevent and control disease, injury and/or disability.

Required by Law:
We must use or disclose your health information when required to do so by the law (i.e., Court or administrative orders, subpoena, discovery request or other lawful process). We will use and disclose your information when requested by national security, intelligence and/or other State or Federal officials and/or if you are an inmate or otherwise under the custody of law enforcement.

Abuse or Neglect:
We may disclose your health information to appropriate authorities if we have reason to believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. This information will be disclosed only to the extent necessary to prevent a serious threat to your health or safety or that of others.

Marketing Health Related Services:
We will not use your health information for marketing purposes.

National Security:
The health information of Armed Forces personnel may be disclosed to the military authorities under certain circumstances. If the information is required for lawful intelligence, counterintelligence or other national security activities, we may disclose it to authorized federal officials.

Appointment Reminders:
We may use or disclose your health information to provide you with appointment reminders including, but not limited to, voicemail messages, post cards or letters.

Your Privacy Rights as a Patient of Dr. Susan L. Marra

Access:
Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian). There will be some limited expectations. If you wish to examine your health records, you will need to complete and submit an appropriate request form. You may contact the office for information regarding this at (206) 299-2676. Once approved, an appointment can be made to review your records. Copies, if requested will be $0.40/copy and the staff time charged will be $50.00/hour including the time to locate and copy your records. If you want copies mailed to you, postage will be charged to you as well. If you prefer a written summary or an explanation of your health information, we will provide that service at $500.00/hour (Disability, Insurance, Employer). Please contact our office for this information.

Amendment:
You have the right to amend your healthcare information if you feel it is inaccurate or incomplete. Your request must be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied.

Restrictions:
You have the right to request that we place additional restrictions on the use or disclosure of your health information. We do not have to agree with the restrictions, but if we do, we will abide by the agreement (except in emergencies). Please contact the office if you want to further restrict access to your healthcare information. This request must be submitted in writing and mailed or faxed to our office at (206) 522-7410.

Questions and Complaints:
You have the right to file a complaint with our office if you feel that we have not complied with the above privacy policy. If you feel that we have violated your privacy rights, or if you disagree with a decision that we have made regarding access to your health information, you can complain to the office in writing. We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint.

Patient Authorization to Disclose, Release or Obtain Protected Health Information

Information to be released to:
Dr. Susan L. Marra, MS, ND, PLLC
17791 Fjord Dr NE
Poulsbo, WA 98370
Tel: (206) 299-2676  |  Fax: (206) 522-7410

Informed Consent for Telemedicine Services

Telemedicine involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records
• Medical images
• Live two-way audio and video
• Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.

Expected Benefits

• Improved access to medical care by enabling a patient to remain in his/her local healthcare site (i.e., home) while the physician consults and obtains test results at distant/other sites.
• More efficient medical evaluation and management.
• Obtaining expertise of a specialist.

Possible Risks

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

• In rare cases, the healthcare provider may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient, or at least a rescheduled video consult;
• Delays in medical evaluation and treatment could occur due to deficiencies or failure of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgement errors.

Notice of Privacy Practices

Information received or created during delivery of telehealth services is subject to our Notice of Privacy Practices which may be found at www.drsusanmarra.com.

By accepting Dr. Marra's invitation to participate in telemedicine visits via doxy.me you acknowledge that you understand and agree with the following:

1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my written consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand the alternatives to telemedicine consultation as they have been explained to me, and in choosing to participate in telemedicine consultation, I understand that some parts of the exam involving physical tests will be conducted by myself or others at my location (i.e., vital signs like weight, temperature, blood pressure, and pulse), at the direction of my consulting healthcare provider, Dr. Marra.
4. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas.
5. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
6. I understand that my healthcare information may be shared with other individuals for scheduling or billing purposes. Others may also be present during my telemedicine consultation in order to operate the audio visual equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: 1) omit specific details of my medical history/physical examination that are personally sensitive to me; 2) ask non-medical personnel to leave the telemedicine examination room; and/or 3) terminate the consultation at any time.
7. I acknowledge receipt of the Notice of Privacy Practices.

Patient Consent to the Use of Telemedicine

I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction.

I have read this document carefully and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.

By accepting Dr. Marra's invitation to participate in a telemedicine visit via doxy.me, I hereby authorize Dr. Marra to use telemedicine in the course of my diagnosis and treatment.

Your secure video call invitation will be sent to the email address you provided on the Patient Information page. Your email is only used to send you an invite to have a secure video call.

Informed Consent for Treatment of Persistent Lyme Disease/TBD

There is considerable uncertainty regarding the diagnosis and treatment of Lyme disease. No single diagnostic and treatment program for Lyme disease is universally successful or accepted. Medical opinion is divided, and two schools of thought regarding diagnosis and treatment exist. Each of the two schools of thought is described in peer-reviewed, evidence-based treatment guidelines. Until we know more, patients must weigh the risks and benefits of treatment in consultation with their doctor.

My Diagnosis

The diagnosis of Lyme disease is primarily a clinical determination made by my doctor based on my exposure to ticks, my report of symptoms, and my doctor's observation of signs of the disease, with diagnostic tests playing a supportive role. Doctors differ in how they diagnose Lyme disease.

• Some physicians rely on the narrow surveillance case criteria of the CDC for clinical diagnosis even though the CDC itself cautions against this approach. These physicians may fail to diagnose some patients who actually have Lyme disease. For these patients, treatment will either not occur or will be delayed.
• Other physicians use broader clinical criteria for diagnosing Lyme disease. These physicians believe it is better to error on the side of treatment because of the serious consequences of failing to treat active Lyme disease. These physicians sometimes use the antibiotic responsiveness of a patient to assist in their diagnosis. Since no treatment is risk-free, use of broader clinical criteria to diagnose disease could in some cases expose patients to increased treatment complications. This approach may result in a tendency to over diagnose and over treat Lyme disease.

My Treatment Choices

The medical community is divided regarding the best approach for treating persistent Lyme disease. Many physicians follow the treatment guidelines of the Infectious Diseases Society of America (IDSA) that recommend short-term treatment only and view the long-term effects of Lyme disease as an autoimmune process or permanent damage that is unaffected by antibiotics.¹ Other physicians believe that the infection persists, is often associated with other tick-borne co-infections, is difficult to eradicate, and therefore requires long-term treatment with intravenous, intramuscular, or oral antibiotics, frequently in high and/or combination or pulsed dosing. These physicians follow the guidelines promulgated by the International Lyme and Associated Diseases Society (ILADS), which recognize that commercial diagnostic tests may be insensitive and that diagnosis and treatment must be based on the physician's clinical judgment and that the risk/benefit of any treatment must be individualized.²

Potential Benefits of Treatment

Some clinical studies support longer term treatment approaches, while others do not. The experience in this office is that although most patients improve with continued treatment, some do not.

Risks of Treatment

There are potential risks involved in using any treatment, just as there are in foregoing treatment entirely. Some of the problems with antibiotics may include (a) allergic reactions, which may manifest as rashes, swelling, and difficulty with breathing, (b) stomach or bowel upset, or (c) yeast infections. Severe allergic reactions may require emergency treatments, while other problems may require suspension of treatment, or adjustment of medication. Other problems such as adverse effects on liver, kidneys gallbladder, or other organs may occur.

Factors to Consider My Decision

No one knows the optimal treatment of symptoms that persist after a patient is diagnosed with Lyme disease and treated with a simple short course of antibiotic therapy. The appropriate treatment may be supportive therapy without the administration of any additional antibiotics. Or, the appropriate treatment might be additional antibiotic therapy. If additional antibiotic therapy is warranted, no one knows for certain exactly how long to give the additional therapy. By taking antibiotics for longer periods of time, I place myself at greater risk of developing side effects. By stopping antibiotic treatment, I place myself at greater risk that a potentially serious infection will progress. Antibiotics are the only form of treatment shown to be effective for Lyme disease, but not all patients respond to antibiotic therapy. There is no currently available diagnostic test that can demonstrate the eradication of the Lyme bacteria from my body. Other forms of treatment designed to strengthen my immune system also may be important. Some forms of treatment are only intended to make me more comfortable by relieving my symptoms and do not address any underlying infection.

My decision about continued treatment may depend on a number of factors and the importance of these factors to me. Some of these factors include (a) the severity of my illness and degree to which it impairs my quality of life, (b) whether I have co-infections, which can complicate treatment, (c) my ability to tolerate antibiotic treatment and the risk of major and minor side effects associated with the treatment, (d) whether I have been responsive to antibiotics in the past, (e) whether I relapse or my illness progresses when I stop taking antibiotics, and (f) my willingness to accept the risk that, left untreated, a bacterial infection potentially may get worse. For example, if my illness is severe, significantly affects the quality of my life, and I have been responsive to antibiotic treatment in the past, I may wish to continue my treatment. However, if I am not responsive to antibiotics, I may wish to terminate treatment. I will ask my doctor if I need any more information to make this decision and am aware that I have the right to obtain a second opinion at any time if I think this would be helpful.

I realize that the choice of treatment approach to use in treating my condition is mine to make in consultation with my physician. After weighing the risks and benefits of the two treatment approaches, I have decided:

I understand the benefits and risks of the proposed course of treatment, and of the alternatives to it, including the risks and benefits of foregoing treatment altogether. My questions have all been answered in terms I understand. All blanks on this document have been filled in as of the time of my signature.

For more information on the treatment approaches used in diagnosing and treating Lyme disease, the IDSA guidelines are available free at: https://www.idsociety.org/practice-guideline/lyme-disease/

¹ Wormser GP, RJ Dattwyler, ED Shapiro, AJ Halperin, AC Steere, MS Klempner, PJ Krause, JS Bakken, F Strle, G Stanek, L Bockenstedt, D Fish, JS Dumler, and RB Nadelman. The clinical assessment, treatment, and prevention of Lyme disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2006; 41(1 November): 1089.
² The International Lyme and Associated Diseases Society. ILADS Evidence-based guidelines for the management of Lyme disease. Expert Rev. Anti-infect. Ther. 2004; 2(1): S1–S13.

Dr. Susan L. Marra, MS, ND, PLLC
Physician-Patient Arbitration Agreement

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration pursuant to Washington law, and not by a lawsuit or resort to court process except as Washington law may provide for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a judge or jury, and instead are accepting the use of arbitration.

Both parties have reviewed the provisions of Washington law (RCW 7.70A.010-7.70A.090) that govern arbitration of claims relating to health care. The patient and the health care provider agree that should legal action pursued by the patient, or on the patient's behalf, both the patient and the health care provider will confirm in their legal documents initiating a lawsuit (Complaint) and/or in responding to a lawsuit (Answer to Complaint) their election to arbitrate the legal issues.

Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all claims or controversies whether in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by the below identified physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers (hereinafter collectively referred to as "Physician") to a patient, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean both the mother and the mother's expected child or children.

Filing by Physician of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Physician, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his/her attorney. The arbitration will be conducted pursuant to Washington law as set forth in RCW 7.70A.030-.040.

The parties agree to the following provisions:

• The arbitrator may not make an award for economic and noneconomic damages in excess of One Million Dollars ($1,000,000.00).
• The fees and expenses of the arbitrator shall be paid by the non-prevailing party.
• The parties agree to the following limitations on preparing each party's case (discovery) to:
  1. 25 interrogatories, including subparts;
  2. 10 requests for admissions;
  3. Requests for production per the Civil Rules;
  4. A physical and mental examination per the Civil Rules;
  5. Deposition of the parties and any expert expected to be called at arbitration may be conducted. Depositions shall not exceed four hours unless the arbitrator issues an order based on good cause for additional time;
  6. Unless the arbitrator issues an order for exceptional circumstances, each party is limited to five depositions of persons who are not parties or experts. Each deposition will not exceed two hours in length;
  7. The deposition of a fact witness will not exceed one hour of examination for each side;
  8. Each party is limited to two (2) experts on liability, two (2) experts on damages, and one (1) rebuttal expert. If there are multiple parties on one side, the arbitrator shall determine the number of experts based on the minimum number to ensure a fair and economic resolution of the action.

There is no right to a trial de novo on appeal (requesting a trial judge to review the arbitration proceedings), other than as outlined under RCW 7.04A.230(1)(a)-(d) and 7.04A.240, or equivalent provisions in a successor statute.

The parties shall bear their own costs, fees and expenses.

Article 4: Retroactive Effect: The patient intends this agreement to cover all services rendered by Physician not only after the date it is signed (including, but not limited to, emergency treatment), but also before it was signed as well.

Article 5: Revocation: This agreement may be revoked by written notice delivered to Physician within 30 days of signature and if not revoked will govern all medical services received by the patient.

Article 6: Severability Provision: In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of the Agreement enforced in accordance with Washington law.

I understand that I have the right to receive a copy of this agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

Physician: Susan L. Marra, MS, ND

Review & Sign

Your signature below applies to each of the following documents, which you have reviewed and acknowledged on the previous pages:

• New Patient Intake
• Financial Responsibility & Fee Schedule
• Office Guidelines
• HIPAA Consent Notice of Privacy Practices
• Patient Authorization to Disclose, Release or Obtain Protected Health Information
• Informed Consent for Telemedicine Services
• Informed Consent for Treatment of Persistent Lyme Disease/TBD
• Physician-Patient Arbitration Agreement