Patient Agreement

  1. I understand that Dr. Levy is treating me as an integrative/holistic medicine specialist and is not serving as my primary care physician.

  2. I understand that Dr. Levy does not use an answering service – his cell phone number is provided to all patients. Messages on Dr. Levy’s cell phone are frequently retrieved, and all messages from patients are responded to within a reasonable time. In the event of an emergency, the Patient should either contact their primary care physician or go directly to an emergency room.

  3. I understand that the Patient is responsible for payment in full for office visits at the time of service, and that Dr. Levy does not participate with any health insurance plans in his office practice. Office visits may be scheduled for 15 minutes ($60), 30 minutes ($120), 45 minutes ($180), or 60 minutes ($240). The Patient will only pay for the actual amount of time used during the visit, as outlined in in #4 below.

  4. I understand that Dr. Levy charges in 5-minute increments at a rate of $240/hour ($20 for each 5-minute increment) for phone calls, email exchanges (email correspondence requires a signature on an email consent form), office visits, prescription refills, and completion of forms. Payment for these services is due by check or money order within 30 days of receipt of a bill.

  5. I understand that the hourly rate for services may change – Dr. Levy will provide advance notice of any changes in rate.

  6. I understand that there is a charge of $100 for missed appointments, and for appointments which are cancelled with less than one business days’ notice.

  7. I understand that checks returned for insufficient funds will result in an additional charge to the Patient of $30.

Click the "Online Patient Agreement" button below to fill out a digital version. The form is HIPAA compliant. Once Signed, you, as well as Dr. Levy, will receive a signed version of your Patient Agreement via email (with your personal information hidden in the email, for HIPAA compliance).

Note: After completing the Patient Agreement, call Naurene at (716) 867-4881 to schedule an appointment.

Page Updated March 30, 2024