NEW PATIENT INTAKE

OFFICE POLICIES

Medical Records Release - Should you need copies of your records or other documents including receipts and income tax-related documentation, please note the following in accordance with Florida Statutes, and is payable prior to receiving the copies.  For copies of records or reports, a minimum of ten (10) working days and not more than thirty (30) may be required to process your request. A completed and signed record release must be done before any records are released.

Forms & Reports - There will be a $25-$150 administrative fee for forms such as disability reports and letters of medical necessity. The fee will be determined based on the complexity of the document. Please allow seven (7) to twenty (20) days for these reports to be completed. We do not fill out disability forms at this facility.

Policy Regarding Minors - We love children at East Lake Acupuncture; however, due to safety and noise issues we ask that all children be left at home. For safety reasons, children are prohibited from waiting in a treatment room while parents/guardians receive treatment. Minors under 12 cannot be left unattended in the lobby, and cannot be left in the lobby or treatment room with a “babysitter”. Staff is prohibited from babysitting/watching children.

Family & Friends - With the exception of a parent accompanying a minor receiving treatment or a caretaker accompanying a disabled individual who requires their presence in the treatment room, or requires a translator, family and friends are asked to wait offsite whenever possible. Our lobby is small. Seating is reserved for patients.

Phones- This is a place of calm and quiet. Cell phone use in common areas is prohibited. Please step outside if you need to make or take a call. Phone use during treatment is prohibited for safety and noise purposes. Please use headphones if watching videos or listening to your own music. 

Refunds - Refunds on products will only be offered if they are returned within fourteen (14) days of the date of purchase and are unopened, with the seal still intact. There are no refunds on services rendered, injections given, or opened products for any reason. There are no refunds or exchanges on rendered services or procedures, including injections. No exceptions. 

Appointment Deposits: Due to the high demand and limited availability of new patient appointments, we require a $50 deposit is required to hold all new patient appointments.  Deposits will be applied to the cost of the visit or held on account to cover fees, copays, co-insurance, or purchases. We do not require a new patient deposit for veterans booked through the VA. We require two business days (48 hours) notice to cancel or reschedule the visit. 

No-Show/Late Cancellation Policy (does not apply to VA patients) A $50 deposit is required to hold new patient visits (does not apply to VA referrals). If a new patient appointment is missed or not canceled with 48 hours prior notice to the scheduled time, the $50.00 fee is forfeited. If an established patient appointment is missed or not canceled with 24 hours prior notice to the scheduled time, a fee of $35.00 for acupuncture and medical services applies. 

Massage therapy: The full price of the service will be charged for massage therapy. All “no-show” or “late cancellation” fees are to be paid in full on or before the next visit and are subject to collections. Insurance will not reimburse the patient for this charge, nor will we bill your insurance for the missed visit. Our office staff makes appointment confirmation by text as a courtesy, though it is the patient’s responsibility to remember his/her appointment date and time. Patients with a history of missed appointments or late cancellations may be required to pay a deposit to hold future appointments or may be limited to same-day appointments only. No-show/late cancellation fees do not apply to veterans booked through the VA. 

Non-Discrimination: Admission to our clinic is non-discriminatory for services rendered, regardless of race, color, sexual orientation, nationality, political affiliation, disability, or age. All patients who come to our clinic for services are protected against discrimination assured by Title VI of the Civil Rights Act of 1964. Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975.

Insurance: As a courtesy, we will do our best to pre-verify your coverage and bill your insurance for the services provided during your visit(s); however, it is your responsibility to know your policy benefits and limitations. Our billing agent is available to answer questions you may have regarding our billing procedures. Please be aware that costs for each session may vary, depending on the procedures performed. A quote of benefits and/or authorization does not guarantee a payment or verify eligibility. Payment of benefits is subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service.

Uninsured discounts. We recognize the significant financial burden medical expenses create for patients with limited or no healthcare coverage. We will offer uninsured patients a similar discount to the discount taken by our contracted insurance carriers. Please ask about our most current posted fee schedule, as fees are subject to change from time to time.

Collections: In compliance with relevant state and federal laws, and in accordance with the provisions outlined in this Billing and Collections Policy, East Lake Acupuncture may engage in collection activities—including extraordinary collection actions (ECAs)—to collect outstanding patient balances. Patients or their responsible parties are expected to pay their full liability for services rendered within thirty (30) days of receipt of their first bill or in accordance with a mutually agreed upon installment payment plan. In the event the account becomes delinquent and is turned over to a collection agency, there will be a $50.00 fee for each account that you are responsible for, as well as any actual collection, court, or attorney fees.

Responsibility for Personal Valuables: We do not provide facilities for the safekeeping of valuables and are not responsible for lost, stolen, or damaged personal items that you or anyone accompanying you may bring into the facility. Please monitor your belongings and be sure to take your belongings with you when you leave.

If you have any questions or concerns, please discuss them with us prior to signing. 

By my signature below, I certify that I have read and understand East Lake Acupuncuture's Office Policies, I and I agree to abide by these policies. 

INFORMED CONSENT FOR TREATMENT AND CARE

I voluntarily request and consent to acupuncture and other treatment provided by a licensed healthcare provider at East Lake Acupuncture acting within the provider's lawful scope of practice.

Depending on my condition and treatment plan, treatment may include acupuncture, electroacupuncture/electrical stimulation, moxibustion, cupping, gua sha, Tui Na/therapeutic massage, myofascial and trigger-point techniques, other manual therapies, physical and rehabilitative medicine modalities, nutritional and lifestyle counseling, Chinese herbal medicine and nutritional supplements, and other procedures within the provider's lawful scope of practice. Certain procedures, including Acupoint Injection Therapy (AIT), may require additional procedure-specific consent.

I understand that my provider will determine which treatments, techniques, locations, intensity, and duration are clinically appropriate based upon my condition, safety, response, and tolerance. I have the right to ask questions and may refuse or withdraw consent for any treatment or procedure at any time.

ACUPUNCTURE AND ELECTROACUPUNCTURE

Acupuncture involves inserting sterile, single-use needles into selected areas of the body. Electrical stimulation may be applied to acupuncture needles when clinically appropriate.

I understand that acupuncture is generally considered safe when performed by a properly trained and licensed practitioner; however, no medical procedure is entirely without risk. Possible effects or complications may include temporary pain or soreness, bruising, minor bleeding, redness, swelling, itching, numbness or tingling, temporary aggravation of symptoms, dizziness, lightheadedness, or fainting.

Uncommon or rare complications may include infection, nerve injury, burns associated with heat therapies, or injury to internal structures. Pneumothorax (puncture of a lung) is a rare but potentially serious complication of needling in certain areas of the body.

East Lake Acupuncture utilizes Clean Needle Technique and appropriate infection-control and anatomical safety procedures.

I agree to promptly tell my provider if I experience unusual pain, dizziness, shortness of breath, significant bleeding, or other unexpected symptoms during or following treatment.

ACUPOINT INJECTION THERAPY AND OTHER NEEDLE-BASED PROCEDURES

When clinically appropriate and separately agreed upon, Acupoint Injection Therapy (AIT) may involve injection of permitted substances into acupuncture points, trigger points, muscles, or subcutaneous tissues.

Possible risks include pain, tenderness, bruising, bleeding, swelling, infection, temporary aggravation of symptoms, nerve or tissue injury, and allergic or other adverse reactions to an injected substance.

Bloodletting or other therapeutic skin-pricking techniques, when performed, involve puncturing the skin with a sterile, single-use device to produce a small amount of bleeding. Possible effects include temporary pain, bruising, bleeding, soreness, lightheadedness, and infection.

I understand that my provider may require a separate consent before performing Acupoint Injection Therapy or another procedure carrying additional procedure-specific risks.

CUPPING AND GUA SHA

Cupping uses suction applied to the skin, while gua sha involves controlled scraping or friction over the skin with an appropriate instrument.

I understand that these treatments commonly cause temporary redness, petechiae, or circular bruise-like discoloration. These marks may remain visible for several days and occasionally longer. Temporary tenderness, soreness, itching, or skin sensitivity may also occur.

Less common complications may include significant bruising, skin irritation, blistering, burns when heat or fire-cupping techniques are used, or infection if the skin is damaged.

My provider will determine the appropriate treatment area, technique, intensity, and duration based on clinical judgment, safety, and my tolerance.

I agree to immediately inform my provider if a procedure becomes excessively painful or uncomfortable or if I have impaired ability to feel pain, temperature, or pressure.

If blistering, significant skin irritation, or another unexpected reaction occurs after treatment, I will contact East Lake Acupuncture for evaluation and appropriate instructions rather than intentionally opening or treating the area without appropriate guidance.

MANUAL THERAPIES AND REHABILITATIVE MODALITIES
Treatment may include Tui Na or therapeutic massage, myofascial release, trigger-point therapy, stretching, joint or soft-tissue mobilization, therapeutic exercise, and other physical or rehabilitative medicine modalities within the provider's scope of practice.

I understand that temporary soreness, tenderness, fatigue, bruising, or temporary aggravation of symptoms may occur. I agree to communicate any excessive discomfort or unexpected reaction to my provider.

CHINESE HERBAL MEDICINE, NUTRITIONAL SUPPLEMENTS AND FOOD THERAPY
Chinese herbs and nutritional supplements may contain ingredients derived from plants, minerals, or other lawful sources and may contain or come into contact with potential allergens.

Possible adverse effects may include nausea, abdominal discomfort, gas, vomiting, diarrhea, constipation, headache, rash, hives, itching, or allergic reaction. Herbs and supplements may also interact with prescription medications, over-the-counter medications, other supplements, or medical conditions.

I agree to provide my provider with accurate and current information concerning my medications, supplements, allergies, medical conditions, and pregnancy or nursing status and to notify my provider of significant changes.

I understand that herbs and supplements should be taken only according to the instructions provided. I will promptly report any unexpected or adverse reaction.

PREGNANCY AND CHANGES IN HEALTH STATUS
I agree to inform my provider if I am pregnant, believe I may be pregnant, am attempting to become pregnant, or become pregnant during my course of treatment.

I also agree to inform my provider of significant changes in my health, new diagnoses, surgeries or procedures, new medications, medication changes, allergies, infections, or other information that may affect the safety or appropriateness of treatment.

ALTERNATIVES AND COORDINATION OF CARE

I understand that alternatives to the treatments offered at East Lake Acupuncture may include declining treatment, seeking evaluation or treatment from another healthcare professional, medication, physical or occupational therapy, chiropractic or other rehabilitative care, diagnostic testing, specialist evaluation, surgery, or other treatment appropriate to my individual condition.

Acupuncture and complementary therapies are not intended to replace emergency medical care or medically necessary evaluation, diagnosis, or treatment by other healthcare professionals.

I understand that my provider may recommend that I seek evaluation or treatment from another healthcare professional when appropriate.

NO GUARANTEE OF RESULTS
I understand that individual responses to treatment vary. No provider at East Lake Acupuncture has made or can make a guarantee, warranty, or promise regarding the outcome of treatment, the degree of improvement I may experience, or the number of treatments that may be necessary.

I understand that it is not possible to anticipate or describe every possible risk, side effect, or complication. I authorize my provider to exercise appropriate professional judgment during treatment based upon my condition and the information reasonably available at that time.

INFORMED CONSENT AND ACKNOWLEDGMENT
I acknowledge that I have read, or have had read to me, this Informed Consent for Treatment and Care and have had the opportunity to ask questions regarding the treatments, procedures, potential benefits, material risks, side effects, alternatives, and my treatment plan.

I understand that I may ask additional questions at any time and may refuse or withdraw my consent to a particular treatment or procedure.

I voluntarily consent to treatment at East Lake Acupuncture. Unless I withdraw my consent, I intend this general consent to remain applicable throughout my course of care for my present condition and any future condition for which I voluntarily seek treatment, except when a separate procedure-specific consent is required.

I acknowledge that additional information regarding treatments and procedures may be provided through treatment-specific consent forms, patient handouts, educational materials, office materials, and East Lake Acupuncture's website.

PRACTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

East Lake Acupuncture is committed to protecting the privacy of your protected health information (PHI).

How We May Use and Disclose Your Health Information - We may use or disclose your health information without a separate written authorization when permitted or required by law, including:

Treatment: To provide, coordinate, or manage your care and to communicate with other health care professionals involved in your treatment.

Payment: To bill you, your health plan, VA Community Care, or another responsible payer and to obtain payment for services.

Health Care Operations: For practice administration, quality improvement, credentialing, auditing, compliance, and other lawful health care operations.

Other Permitted or Required Uses: When required by law or for certain public health, health oversight, workers' compensation, law-enforcement, judicial or administrative, and other legally authorized purposes.

Other uses and disclosures of your health information will be made only with your written authorization when authorization is required. You may revoke authorization in writing, except to the extent we have already acted in reliance on it.

Specially Protected Information - Certain health information may receive additional protection under federal or Florida law. When applicable, East Lake Acupuncture will follow the law providing greater privacy protection.

If we maintain or receive substance use disorder treatment records protected by 42 CFR Part 2, those records may have additional protections, including restrictions on their use or disclosure in certain civil, criminal, administrative, or legislative proceedings against the patient.

Your Privacy Rights - You have the right to:

• Obtain an electronic or paper copy of your medical record and other health information, subject to applicable law.
• Ask us to correct or amend health information you believe is incorrect or incomplete.
• Ask us to restrict certain uses or disclosures. We are not required to agree to every request unless required by law.
• Request confidential communications or ask us to contact you in a specific way or at a specific location.
• Receive an accounting of certain disclosures of your health information.
  Receive a paper copy of this Notice at any time.
• Choose someone with legal authority to act for you, such as a personal representative.
• File a complaint if you believe your privacy rights have been violated. We will not retaliate against you for filing a complaint.
• Our Responsibilities - East Lake Acupuncture will safeguard your health information and use or disclose it only as permitted or required by applicable federal and Florida law. We may change this Notice and make the revised Notice effective for health information we already maintain as well as information we receive in the future.

The current Notice will be available at our office and through any other method required by applicable law.

Questions or Complaints - If you have questions about this Notice or believe your privacy rights have been violated, contact: East Lake Acupuncture - Privacy Officer: PO Box 700215, St. Cloud, FL 34770

You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Filing a complaint will not affect your care, and East Lake Acupuncture will not retaliate against you for filing a complaint.

 

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Our Notice of Privacy Practices provides information about how East Lake Acupuncture may use and disclose your protected health information and when we need your written authorization to do so. This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

If you want a family member, friend, or companion to be able to make or change appointments, accompany you into the treatment room (restrictions apply), or discuss your care with your provider, you must complete this form, which is available at the front desk. A separate authorization is required for each designee.

Privacy Policy. All records are kept strictly confidential and are subject to HIPAA compliance and will not be shared with any outside establishment, individual, organization, or medical facilities without explicit written consent from the client (you) or the client’s legal guardian. Unless legally required by local, state, or federal subpoena, summons, or other court order. Copies of our detailed Privacy Policy are available upon request, on our website (https://tinyurl.com/3pxdea5d) and are posted near the front desk and are on the clipboards containing the new patient paperwork. You may request a copy via email by emailing us at info@eastlakeacu.com.

By my signature below, I certify that I been given the opportunity to review and request a copy of East Lake Acupuncture, LLC’s Notice of Privacy Practices and Office Policies (posted in the reception area & on intake clipboards) on the date indicated below.