Rima E Laibow Associates 3769 E. Calle Fernando Tucson AZ 85716 +1-908-337-6115
[email protected] NON-CONSENSUAL EXPERIMENTATION AND TARGETING CLIENT CONTRACT Dear Potential Consulting Client, In an effort to make our relationship successful, I would like to provide you with some facts about your participation and my fees: Initial application to be considered for services relating to non-consensual human experimentation or other individual non-consensual targeting is made by your filling out the provided forms and following the instructions provided at http://drrimatruthreports.com/securing-help-as-a-targeted-individual-ti/ and on the forms themselves in full and sending them in hard copy format along with a non-refundable check in the amount of $1000 (US) made out to Rima E. Laibow Associates to the following address. Rima E Laibow Associates 3769 E Calle Fernando Tucson AZ 85716. Please make sure you use a system which allows tracking of your package. Upon receipt of your application your check will be deposited. Once it has cleared an initial appointment will be scheduled for your Initial Consultation Meeting. During that appointment, which will be recorded, you will initially meet electronically with a member of our medical team, our toxicological team and our legal team. Following our assessment appointment, which is scheduled for 1 hour, our team members will hold a case conference, discuss your case and documents and determine whether we can accept you as a participant in our services. Following the Initial Consultation Meeting, you will receive a written report which will inform you whether you have been accepted for our program which typically includes evaluation and formal reports in the following areas:
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Medical and psychiatric/emotional Toxicological Implant documentation Implant characterization Possible implant extraction Ownership/patent documentation Detoxification/restoration Legal Consultation and referral Medical Consultation and referral Professional supervision of investigation and subsequent activities as desired
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Prior to scheduling the Initial Consultation Meeting, ALL FORMS AND DOCUMENTATION MUST BE COMPLETED AND YOUR PAYMENT MUST HAVE CLEARED. Your initial report following your interview with our team members will contain information that may be useful to you, including a proposed course of action with our team. If you elect to follow that course of action, you understand that each part of it has a separate fee structure and that you will be responsible for those fees. You further understand that all reports and information provided to you is protected by Copyright by members of the team; that it remains the property of the individual or organization which provided it to you and that you may use that material only in certain permitted ways. Any other use, including any form of publication in whole or part, is prohibited unless permitted in writing signed by the professional or company involved. Permitted uses include sharing them with your legal counsel, medical personnel and spouse or guardian. Prohibited uses include posting on the internet, sharing the names of professionals and reports in a way that may endanger them, sharing their names, addresses and other contact information without written permission to do so and any other breach of the documents you have signed. None of the professionals or corporations accepts insurance payment for their services, which are entirely at your direct out of pocket cost. Documentation can be provided at no additional charge which you can submit to your non-Medicare insurance programs if you choose. You should be aware that your insurance plan may not cover out of network or consultative services, nor may they cover other fees and services involved in services provided to you by our team of consultants and laboratories. Please note that if you are a Medicare patient, we must have a private contract in place before our team is able consult with you. A copy of the contract is provided If you are not covered by Medicare, please disregard the attached Medicare Private Contract. If you are covered by Medicare, print out, fill out completely and return the completed and signed contract to me in hard copy. Please note that if you are covered by Medicare and opt to enter into a consultative relationship with me and with our team Medicare will not reimburse you for my services and neither you nor I are permitted to submit any billing to your Medicare program or secondary coverage insurance program on your behalf for these non-covered, private contract services. Time is a precious resource for you and for our team Therefore, large blocks of time are reserved for you and we cannot reschedule appointments cancelled on short notice. If you must cancel an appointment, please email the person with whom you have that appointment at as soon as possible. You will be charged for appointments missed or not cancelled in writing via email or text 48 hours or more in advance.
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The client or guarantor by signature on this application indicates that all retainers and bills will be paid upon receipt. Interest at ½ of 1% per month on the unpaid balance may be charged for any amount due
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If adequate written or texted notice is given, or if there has been a true emergency, subject to the judgement of the professional or company whose appointment you missed, your appointment will be rescheduled. If these conditions are not met, however, your appointment will not be rescheduled and you will be charged in full for that appointment.
over 15 days. Should an account have to be forwarded to an attorney for collection, reasonable attorney's and other fees shall also be due. I encourage you to ask any questions you have about billing policy or about any other aspect of our work together. Please note that our services are consultative and we do not offer direct clinical services. Our input, advice and information are offered as health consultation and coaching, toxicology and legal services. You are advised to have a primary health care provider. You further agree that you understand that our suggestions, consultations and health coaching may include options and information not offered to you by your primary health or other provider and the choice to access or use any of these strategies and options rests solely with you. You agree to be responsible for compensation as outlined above for our time and services, whether direct or indirect, when focused on your needs. You understand that any services that are proposed will be explained to you fully in terms of both the nature of the service itself and the cost. While your biometric and other data is your property, any reports or conclusions expressed in writing and our personal, professional or corporate names are protected by copyright laws and remain our exclusive property. As such, their use other than for your personal review and that of any attorney or other physician or health care provider you consult, may be carried out only with our explicit written permission. When submitting this document, please make sure to: 1. Sign and date completely, printing legibly where required 2. Return by physical mail as a hard, originally signed, copy. 3. Include a front and back copy of a government issued ID such as a Driver’s License or Face Page of a Passport issued to the client and, if there is a sponsor, to the sponsor as well. 4. Include summary of your condition and history which is no more than two pages long which indicates what results you are hoping for in a consultation with us.
I am a Medicare Patient ____ YES ____ NO (Select one) If Yes, a Private Contract will be required before consultation can take place. See attached Private Contract
Print Name of Client
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___________________________________________ __________________________________ Client Date of Birth Client Country of Birth
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___________________________________________ _________________________________ Signature of Sponsor Relationship to Client
___________________________________________ __________________________________ Social Security or Identify Number Country of Issue ___________________________________________ __________________________________ Street Address, including Apartment Number City, State, Zip Code ___________________________________________ __________________________________ Cell Phone Land Line ___________________________________________ __________________________________ Primary Care Physician Office Phone (including country/area code) I hereby give permission for Dr. Laibow and/or members of the consultation team to speak with the following people on my behalf: ___________________________________________ __________________________________ Name (Print) Relationship ___________________________________________ __________________________________ Phone Number Email ___________________________________________ __________________________________ Name (Print) Relationship ___________________________________________ __________________________________ Phone Number Email Use additional page if necessary I specifically do not want Dr. Laibow or members of the consultation team to communicate with the following people about me: ___________________________________________ __________________________________ Name (Print) Relationship ___________________________________________ __________________________________ Phone Number Email __________________________________________ __________________________________ Name (Print) Relationship ___________________________________________ __________________________________ Phone Number Email
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