In order to maintain the quality of care at the clinic, we have instituted a number of policies, which are outlined below. By signing this form, you agree to abide by these policies:
Diversity: Cup of Life Healing Center does not discriminate based upon age, gender, race, religion, sexual orientation, health status, or the ability to pay. We hope you will join us in honoring diversity.
Confidentiality: I agree to maintain the confidentiality of all other patients of the clinic. Our staff will maintain your confidentiality by not acknowledging you outside of the clinic unless you first acknowledge them.
Privacy Policy: In accordance with HIPAA (Health Insurance Portability and Accountability Act) regulation and New Hampshire Law, Cup of Life Healing Center takes the right to your privacy seriously. Therefore, we do not disclose any personal, health, financial, or any other information about you or the services we provide to you to any third parties without your request or permission. This also includes online services we provide, including access to your appointment information, user-ID, or password.
As healthcare practitioners and administrators, we are also responsible for staying up-to-date with HIPAA regulations and for properly training all staff members and new employees to ensure that your personal health information is not compromised. If at any time you have a concern or complaint about your privacy, please contact Cup of Life Healing Center’s privacy officer or the Office of Civil Rights of the US Department of Health and Human Services.
Appointment reminders: As a courtesy to you, we make every effort to email or text with an appointment reminder one day before each scheduled appointment. If for some reason we do not remind you, the no-show policy still applies if you fail to arrive for your appointment.
Identifying Information: I understand that any published research will not contain identifying information and that my medical record will not be released without my written consent.
Needle safety: During acupuncture, I agree to remain lying down during treatment and not to remove or manipulate the acupuncture needles.
Etiquette: I agree not to come into the clinic under the influence of alcohol or non-prescribed drugs. I agree to turn any cell phone/pager to silent mode. I agree to respect other patients’ relaxation and will keep conversation to a minimum when in the treatment room. I understand that if my behavior does not comply with the policy of the clinic that I may be refused or released from treatment by Cup of Life Healing Center until I agree to comply.
Release of Liability for Lost or Stolen Goods: Cup of Life Healing Center is not responsible for lost or stolen goods. Please do not bring valuables into the treatment room. We cannot guarantee their safety.
Payment: I understand payment is expected at the time of visit. Cup of Life Healing Center accepts cash, check, credit card, debit card as well as FSA or HSA cards. We do not accept insurance but will be happy to provide you with documentation of your treatment that you may file with your insurance company.
Cancellations: We ask for at least 24-hour advance notice if it is necessary to cancel an appointment. All appointments that are canceled with less than 24-hour advance notice, and appointments missed without notice, will be charged the minimum amount for that appointment service. If appointments have been purchased in a package, the missed or canceled appointment will be deducted from the number of remaining appointments in that package. If you miss your appointment or are more than 10 minutes late, you can be seen as a walk-in by the same practitioner with whom you had your original appointment at the practitioner’s discretion. If you want to come later the same day and see a different practitioner, you must pay for both appointments.
I attest that the information provided is true and correct. By signing below, I agree to the policies, consents, and release of liability as set forth in the entirety of this document.