Third Party Coverage

For those with third party coverage, Chicken Soup Chinese Medicine is happy to work with you to bill your insurance carrier. We will work with you on Worker’s Compensation or Personal Injury as well. Please speak with the Office Manager if you have specific questions about your third party or health insurance coverage. We bill your insurance carrier directly. We do not provide Super Bills. We can provide an itemized receipt of services for reimbursements and medical letters of necessity. These can be batched according to your specifications and will be emailed to you. Simply ask the Front Desk.

Non-Direct Assignment of Payment

For patients with insurance carriers that only pay the insured person (patient), we collect coinsurance payment at the time of service. We offer you the courtesy of billing your insurance carrier directly from this office. All patients personally receiving insurance checks must endorse the check and send it to CSCM within 30 days of check date. CSCM receives notice when the insurance company issues these checks. Failure to provide the endorsed check within 30 days will result in a charge of the total amount sent on the credit/debit card on file.

Worker’s Compensation and Personal Injury

All Worker’s Compensation and Personal Injury cases must be pre-approved and/or preauthorized by your insurance carrier in advance of the first session. For all Worker’s Compensation cases a pre-authorization detailing the diagnosis to be treated and the number of approved visits is required. Once your pre-authorized visits end, you must either receive a new pre-authorization or pay for your treatment at the time of service. For Personal Injury cases, when you have met your maximum coverage, we ask that you pay for your visits at the time of the visit. Discuss any alternate arrangements directly with our Office Manager.

Managed Care Plans

For managed care plans with which we have a contract, you must be pre-approved for treatment and we will collect only the required co-payment at the time of each visit. Usually, managed care organizations must approve a treatment plan after the initial visit before you can receive additional treatments.

PPO and EPO Plans

For PPO and EPO plans: once you have met your yearly deductible and CSCM has begun to receive payments from your third party payer, you become responsible for the co-payment and/or co-insurance only up until your benefits are exhausted for the year. CSCM will bill directly for services involving CPT (procedure) and/or ICD-10 (diagnosis) codes that are not covered or paid for by your insurance company or third party payer. If you would like to see our detailed fee schedule, please ask our office manager.

Informed consent for telemedicine services

I hereby agree to participate in a telemedicine evaluation, as a current patient of Chicken Soup Chinese Medicine.

I authorize the electronic transmission of my medical information and/or videoconference session so that it can be viewed by a Chinese medicine doctor, acupuncturist or other practitioner involved in my medical care.

I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my health care provider and consulting health care provider in order to operate the video equipment. The abovementioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

I understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to see a medical professional in person.

I agree that certain situations including emergencies and crises are inappropriate for audio/video/computer-based psychotherapy services. If I am in crisis or in an emergency I should immediately call 911 or go to the nearest hospital or crisis facility.

I understand that medical records of telemedicine services will be kept to ensure continuity of care and help facilitate treatment.

Understanding Treatment Risk

I do give consent to acupuncture treatments and other procedures associated with Chinese Medicine by the staff acupuncturist and/or any guest acupuncturist, tutorial student, or clinic assistant working under their supervision. I understand that methods may include, but are not limited to, acupuncture, moxibustion, cupping, electric stimulation, Tui-Na Chinese massage, herbal medicine, and nutritional counseling. I have been informed that acupuncture is a safe method of treatment, but that it may have side effects, including, but not limited to, bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxibustion. I understand that while this document describes major risks of treatment, other unanticipated side effects may occur. I do not expect the acupuncturist to be able to anticipate all possible complications from treatment, but I do wish to rely on the acupuncturist to exercise judgment during the course of the procedure, which the acupuncturist feels at the time, based upon the facts then known, is in my best interests.

Understanding Herbal Side Effects

The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomach ache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I understand that the herbs need to be prepared and the tea consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant taste or smell. I will immediately notify a member of the clinic staff of any unpleasant effects associated with the consumption of the herbal teas or products. I will notify my practitioner if I am or become pregnant.

Confidentiality and Adherence

I understand the clinic staff may review my medical records and lab reports, but all my records will be kept strictly confidential and will not be released without my consent. Data may be gathered anonymously from files with no identifiers for analytic purposes. It is agreed: With regard to medical care and services, the attending acupuncturist will provide services to the patient and, to the best of their skill and knowledge, medical care appropriate to the situation. The patient will cooperate fully with the acupuncturist by following her instructions and adhering to such treatment plan or course of action as may be set forth and agreed.

Authorization to Release Information

I hereby authorize any health care practitioner, medical service organization, insurance company, or other institution or organization to release to you, and you to them, any medical or other information acquired concerning any condition or other disability. A photocopy of this authorization shall be as valid as the original. I authorize Chicken Soup Chinese Medicine and members of its clinic medical staff and students to review my records for the purposes of collecting statistical data or consent to the publication of statistical and/or clinical data obtained from my records. I understand that if any particulars of my case are used for the purpose of publication, all possible clues to my identity will be disguised or altered. I understand there is a remote possibility of being accidentally identified as the source of the clinical data, but the way information is handled makes the risk extremely small.

Insurance Billing and Payment Agreement

This practice recognizes the responsibility of filling out the practitioner's insurance statement and bill for your insurance and for your accounting purposes. By signing below I hereby irrevocably assign the insurance benefit payments directly to Chicken Soup Chinese Medicine. A photocopy of this authorization is accepted with the same authority as the original. I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this acupuncturist's office will prepare any necessary reports and forms needed to make collection from the insurance company and that any amount over the co-payment paid directly to acupuncturist's office will be reimbursed after receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.

In Summary

By voluntarily signing below, I show that I have read, or have had read to me, this consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment at this clinic.

Missed Acupuncture Treatment Appointments

Running Late

Arrive a few minutes before your scheduled visit. Your appointment time is when the doctor will see you, not when you walk through the door. Plan for time to check-in at our front desk. Let us know if you are running late so we can reschedule for a later time/date if available. In light of the current health crisis, we are unable to extend your appointment visit past the allotted time if you are running late. Please be punctual.

Late Cancellations

If you cancel your appointment with less than 24 hours notice, a fee of $85 will be added to your account and charged to your credit/debit card on file. If you cancel your appointment with less than 48 hours notice, a fee of $50 will be added to your account and charged to your credit/debit card on file. If you miss any appointment without giving any notice, a fee of $129 will be added to your account and charged to your credit/debit card on file (exceptions are made for true emergencies). We will also be concerned, so expect a phone call to make sure you are OK!

If you frequently cancel less than 24 hours in advance, we will have the option to put you on a same-day schedule.

Rescheduling

If you are unable to make your appointment we will waive the late cancellation fee if we can rebook your appointment within the same calendar week. We appreciate that it doesn’t feel good to charge fees for missed appointments so please call and let us help you reschedule you later in the week.

Missed New Patient Intakes & Consultations

• Less than 48 hours notice of cancellation: we reserve to right to hold the full deposit.

• Less than 7 days notice of cancellation: we reserve the right to hold $150 of deposit.

• Rescheduling 7 days in advance: we transfer your deposit to the rescheduled consultation time.

So, if you want to cancel AND receive a full refund of your deposit, we ask that you tell us at least 1 week in advance

We would like to see you, so help us by managing your schedule and committing to the consultation times. We don’t like keeping deposits. Emergencies happen, so inform us as soon as they happen and we will work with you to find a solution.

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Staff Signature: __________________________________

 

Date: _______________________