Basic Information and Consent Form

Please fill out this form as best you can so we can provide you with the most relevant service.

INFORMATION SECTION

Insurance Information (optional)

If you would like us to review your insurance benefits, upload clear photos of the front and back of your insurance card. Coverage cannot be guaranteed.

CONSENT SECTION

Financial Terms and Conditions

I understand that the filing of insurance papers by the above acupuncturist and/or staff is done as a courtesy and does not relieve me of my responsibility. I further understand that the insurance is not a guarantee of payment and if it is subsequently determined that services provided are not a covered benefit by my insurance carrier, I agree to accept full financial responsibility of my bill. I agree that if this account is placed in the hands of an attorney for collection, the undersigned agrees to pay an amount equal to one-third of the unpaid principal and interest (1.5% per month, 18% per annum)as a collection fee, plus court and interest in the amount of 33.3% of the balance due, whether or not the suit is filed beginning 30 days after the monies have become due or expenses have been incurred.

Financial Responsibilities

1. APPOINTMENTS: We request that you keep scheduled appointments and arrive at the appointed time. If you are unable to keep your appointment, please give at least 48 hours notice. Cancellations of less than 24 hours prior to your appointment, or a No-Show for your appointment, will result in a $25 fee per patient. 2. CO-PAYS: According to your insurance contract, you are obligated to pay any co-pay due at the time of service. If you are unable to pay the co-pay at the time of service, we retain the right to cancel or reschedule your appointment to a time when you are prepared to pay your co-pay. Furthermore, if your appointment is kept without payment of the co-pay at the time of service, we retain the right to levy an administrative charge of $10 to your account in order to defray the cost of securing the co-pay. 3. REFERRALS: If your insurance plan requires a referral, the referral must be presented before seeing the acupuncturist. If you do not have the required referral, we reserve the right to reschedule your appointment or you will have to be willing to be responsible for the entire cost of the examination. 4: RETURNED CHECKS: Any payment made by check that does not clear your bank account will result in a fee for insufficient funds. Our fee for insufficient funds is $25 and will be added to your account for each bounced check.

Consent to Services

I have read and understand both the front and back of this form and acknowledge that the purposes, goals, techniques, procedures, limitations, potential risks and benefits of the service(s) to be performed have been explained to me. I have had the opportunity to ask questions regarding the proposed services, this form, and have received satisfactory explanations. I understand that I can request more information at any time if desired. I understand that I have the right to refuse or discontinue any treatment at any time. I understand that this refusal may affect the expected results. I hereby voluntarily consent to acupuncture and/or herbal consultations. Acupuncture and Massage I understand that services rendered address individuals with a wide range of complaints including both acute and chronic healthcare issues. Treatments may include the insertion of sterile needles, bodywork, gua sha (rubbing of the skin with a smooth object), cupping (the application of cups with vacuum to the skin) and/or the application of heat to the skin. I understand that I may refuse any of these techniques at any time. Risks/Possible Side Effects Treatment may result in certain side effects, including local bruising, slight bleeding, fainting, temporary pain and discomfort, and temporary aggravation of symptoms existing prior to treatment. No Guarantees Services rendered address individuals with a wide range of complaints including both acute and chronic healthcare issues. I acknowledge that I have not received any guarantees or promises as to the results from the services provided. Client Responsibilities It is my responsibility as a client to inform my practitioner of all aspects of my health and that, as service progresses, to inform my acupuncturist of changes that occur. I will inform my practitioner if I am pregnant and/or suspect pregnancy at any time. If I experience any pain, discomfort or possible adverse side effects, it is my responsibility to immediately notify my practitioner. Medical Treatment An acupuncturist or massage therapist is not a substitute for a medical doctor and will not suggest that I discontinue medical treatment. I understand that if I am currently under a physician’s care, I should continue as long as my physician deems necessary. It is my responsibility to consult with my physician before altering any prescribed medications or treatments. I understand also that if there is an emergency, or a worsening of my health condition, or if a new condition arises, that I should consult a licensed physician.

Consent to Herbs

Herbal Consultations I understand that herbs are considered to be food supplements and are utilized to strengthen and support overall health and wellness. Herbs, along with nonmedical nutritional suggestions can serve as an excellent adjunct to a medical doctor’s treatment, but are not a substitute for that treatment. An herbalist can neither diagnose nor treat disease. Risks/Possible Side Effects The historical record and modern research indicate that the herbs most often used for healthcare have an exceptional safety record. However, adverse reactions and unintended side effects can sometimes occur when taking herbs. Side effects that have occasionally been reported after using herbs include headaches, skin rashes, and digestive upsets. Such effects generally resolve rapidly, especially if the dosage is reduced or the herb is stopped. Allergic reactions are also very rare but have been reported, usually in individuals with contact allergy to specifics plants. Should adverse reactions or unpleasant side effects occur, I agree to discontinue taking the herbs and contact my herbalist as soon as possible. My herbalist may be able to propose measures to reduce any discomforts or may refer me to a physician or other health-care practitioner. Herb-Drug interaction Although herbs and other supplements have the potential to interact with pharmaceuticals and certain herbs have been shown to have some effect on a limited range of pharmaceuticals, clinically significant interactions between most herbs and prescription drugs are rare or only potentially possible in theory. Nevertheless, some prescribed drugs are very strong and have a narrow range of safe dosage, which makes any interaction more risky. It is the responsibility of the client to disclose fully any medications currently in use, including other herbs and supplements. Clients also are expected to inform their physicians of any herbs or supplements they are using. Any indication that effect of a drug is being altered by simultaneous use of an herb should be reported directly to all health professionals involved. It is also advisable to stop taking herbs at least 48 hours before surgical operation, and in the event of being prescribed anticoagulants, antiepileptic drugs, and digoxin until expert advice is received. Toxicity All of the herbs that we use are generally considered safe and non-toxic at recommended doses for most people; however, it is important that the client use the herbs in accordance with the dosage recommended by the herbalist. As the liver and the kidneys are the body organs most vulnerable to any ingested or absorbed substance, it is also important that the client disclose to the herbalist any past or current disease in either of these organs. Herbs should not be used in pregnancy or lactation without advice of a healthcare practitioner and clients who become pregnant should stop taking herbs until that advice is received. I understand and agree that it is important that I do not exceed the recommended dose of the herbs suggested by my herbalist. I also understand and agree to disclose to my herbalist any previous or current liver or kidney disease or related disease as well as any other condition that I believe may have an impact on my health status.

Notice of Privacy Practices

This notice describes how patient healthcare information about you (as a patient of this practice) may be used and disclosed, how you may obtain access to your health information, and how your patient rights affect the control of this health information. Our practice is required by law to maintain the privacy of your health information, and we are fully confident that our compliance with the policies described below will facilitate the proper protection of your health information. I. Acknowledgement & Consent for the Use and Disclosure of Information Our “Notice of Privacy Practices” policy, available at the reception desk provides detailed information about how we may use and disclose protected health information about you. The details of this policy are in full compliance with all provisions, including those most recently updated, of the Health Insurance Portability and Accountability Act passed in 1996 (HIPAA). Our “Notice of Privacy Practices” states that we reserve the right to change terms within our policy. Should this happen, we will display, and make available, the new policy and its perspective date of implementation. You have the right to request restrictions on how your protected health information may be used or disclosed for treatment, payment, or health care operations. We are not required to agree with your restrictions; however, if we do, we are bound by our agreement with you. By signing below, I acknowledge receipt of “Notice of Privacy of Practices” and consent to the use and disclosure of protected health information about me for treatment, payment, and health care operations. I have the right to revoke this consent, in writing, except where the practice has already made disclosures in trust on my prior consent. II. Personal Representative, Family or Other Entities Authorized Access to Protected Health Information to be Used and/ or Disclosed: Name or specifically identify these persons and/ or other entities you are authorizing to make use of and/or disclose your protected health information regarding treatment, payment, and other healthcare operations. III. Authorization for use of Patient Contact Methods: We may be unable to contact patients directly during normal business hours. On these occasions our office contacts patients and leaves messages through the communication devices provided by our patients. Due to the new federally mandated HIPAA Privacy Rule, we must obtain your authorization to continue this mode of communication. Protected Healthcare Information that we may possibly disclose on your home, work, cell phone, or email account includes, but is not limited to: herbal prescription, appointment instructions for visits and procedures, and scheduling information. IV: The following disclosures are required by law and do not require your consent:  Food and Drug Administration (FDA): This office is required by law to disclose health information to the FDA related to any adverse effects of food, supplements, products, and product defects for surveillance to enable product recalls, repairs, or replacements.  Worker’s Compensation: This office will release information to the extent authorized by law in matters of worker’s compensation.  Public Health: This office is required by law to disclose health information to public health and/or legal authorities to avert a serious threat to health or safety, to report communicable disease, injury, or disability, or to comply with mandated reporting requirements for tracking of birth and morbidity.  Law Enforcement: As required under state or federal law, your health information will be disclosed to appropriate health oversight agencies, public health authorities, law enforcement officials, or attorneys: (1) In response to a valid subpoena/ (2) In the event that a staff member or business associate of this office believes in good faith that one or more clients, workers, or the general public are endangered due to suspected unlawful conduct of a practitioner or violations of professional or clinical standards; (3) When a client is a suspected victim of abuse, neglect or domestic violence. If you have any questions about your rights or believe your privacy rights have been violated, please contact the administrator of the clinic. You have the right to file a complaint with the U.S. Secretary of Health and Human Services (Office of Civil Rights:1-800-368-1019).