Please help your treatment plab by answering some questions below. Your information will be confidential. If you have questions, please ask, and leave blank if unknown. Thank you.

The following questions are in regard to your Bowel movements. 

Patient Information and Consent Form

Herbalism and dietary recommendations may include the ingestion or topical use of plants and foods.  Please inform practitioner if you have any known allergies or sensitivities. 

Is there anything your practitioner needs to know? Apart from the usual medical details, it is important that you let your practitioner know:

if you have ever experienced a fit, faint or dizziness. 

if you have a pacemaker or any other electrical implants .

if you have a bleeding disorder.

if you are taking anti-coagulants or any other medication.

if you have damaged heart valves or

If you have any particular increased risk for infection such as compromised immunity or untreated diabetes. 

I confirm that I have read and understood the above information, and I consent to having  acupuncture, herbal and lifestyle treatment by Anne Cusick L.Ac #1076.

I understand that I can refuse treatment at any time.

 

Colorado Mantatory Disclosure Statement

EDUCATION AND EXPERIENCE:

Anne Cusick L.AC earned her Master of Acupuncture and Oriental Medicine degree from the AOMA Graduate School of Integratice Medicine, April 2008. 

This four-year program consists of 3200 hours of education including 875

hours of clinical practice. She was certified as a Diplomate in Acupuncture and Traditional Chinese Medicine by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) in October 2008. This includes certification in Clean

Needle Technique and Chinese Herbology.

Prior to earning her Master degree in the United States, Anne Cusick L.Ac Graduated from TExas Christian University with a B.A. in Business Finance in 2003.

Anne Cusick L.Ac has practiced acupuncture and Herbal Medicine since getting her texas livensurei n October of 2008 until current with a  Colorado Acupuncture License. 

Anne Cusick’s  training includes adjunctive therapies such as moxibustion, tui na, acupressure, cupping, auriculotherapy, medical herbology, dietary and lifestyle recommendations.

She is a registered and licensed acupuncturist in Colorado. None of these licenses, certificates, or registrations has ever been suspended or revoked.

This clinic complies with the rules and regulations promulgated by the Colorado Department of Health, including the proper cleaning and sterilization of needles and the sanitation of acupuncture offices. Only single-use, disposable, factory-sterilized

needles are utilized.

FEE SCHEDULE:

New Patient Acupuncture Adult (90 min)..........................$125 (Comes with Herbal Consultation as needed or desired) 

Established Acupuncture Patient (75 min) .........................$95

New Patient Herbal Consultation (45 min). .........................$89

Established Herbal Consultation (30 min)..........................$55

New Patient Telehealth Consultation (60 min). ...................$89

Established Patient Telehealth Consultation (30 min)..........$55

Established Senior (75 min).....................$85 (age 65+)

Established Student (75 min)...................................$85

New Child Appointment (75 min). .............................$85

Established Child (60 min)..........$65 (Infant to Age 12)

• Payment due at time of service. Thank you!

• All prices include any additional modalities (moxibustion, massage, ear acupuncture, cupping, electro-stimulation)

• Please make every effort to notify me as far in advance as possible if you are unable to keep an appointment.

A 24 hour advanced notice is required to avoid being charged the current fee for any missed or cancelled appointment.

* $39 Cancellation fee for appointment cancelled 12-36 hours prior to appointment. 

* $85 Cancellation fee for appointments cancelled within 12 hours of appointment time or for no call/no shows for appointment times. 

* Management can waive fees when approved for emergency purposes. 

*At any time within the first three appointments, Anne Cusick L.Ac or the patient (who can  terminate therapy at any time regardless) can deem the treatments not working for any reason without explanation and terminate the treatment relationship. 

* Patient loses the right to reschedule after three cancelled appointments or if the patient no calls/ no shows ( does not call to cancel a set appointment and does not show up for an appointment) by the patient unless allowed by managment and all cancellation fees are fully paid by patient. 

PATIENT’S RIGHTS:

• The patient is entitled to receive information about the methods of therapy, the techniques used, and the duration of therapy, if known.

• The patient may seek a second opinion from another healthcare professional or may terminate therapy at any time.

• In a professional relationship, sexual intimacy is never appropriate and should be reported to the Director of the Division of Registrations in the Department of Regulatory Agencies.

The practice of acupuncture is regulated by the Director of Registrations, Colorado Department of Regulatory Agencies. If you have comments, questions, or complaints, contact the Acupuncturists Registration Office, 1560 Broadway, Suite 1350, Denver, Colorado 80202. Telephone (303) 894-2440.

I have read and understand this document.

 

 • Montrose, CO 81401 • (512)554-6642• anne_cusick@hotmail.com •   www.cusickacupuncture.com

 

 

After being referred by a chiropractor, if after two months or 20 treatments, whichever comes first, no substantial improvement occurs in the condition being treated, I understand that the acupuncturist is required to refer me to a physician. It is my responsibility and choice whether to follow this advice.

Notice of Privacy Policies and HIPPAA agreement

Protecting your privacy and healthcare information is vital in the course of our relationship. I gather personal information and health information in several ways .

Information I receive from you

Information I receive from other healthcare providers

Information from third party payers.

This information is used for treatment, payment, and healthcare operations. I will use this information for treatment, payment, and healthcare operations. Information will only be disclosed when the law allows me to do so. Any other use and disclosure will be made only with your authorization, and you have the right ot revoke your authorization. You can issue and authorization by writing.

I will not use your information in marketing, without your written authorization. I may send birthday cards, holiday cards, thank you cards, newsletters, email appointment availablilities,  and appointment reminders, by mail, text or email.

When required by law I may disclose your protected health information. This includes but is not limited to Public Health needs, Health Oversight requirements, and issues of abuse or neglect, legal proceedings. Patient Rights

Upon written request you have the right to access, review or receive copies of your healthcare records. I will provide copies of your records within 15 days after your request is turned in, and will charge a reasonable, cost-based fee for the records. You have the right to request that I amend your protected Health Information in writing, within reason of the law, and can receive a copy of Health information. You will receive request within 60 days if in accordance with the law.

You have a right to receive all notices in writing.

 

 

I acknowledge that I have been provided with Notice of Privacy Policies. I understand that Anne Cusick L.Ac may need to contact me with appointment reminders or information related to treatments. If this contact is left by phone, a message will be left with a machine or the person who answers. Information stripped of any personal identifiers may be used for research and educational purposes.

 

                                          Canellation Policy 
We understand that situations arise in which you must cancel your appointment. 
It is therefore requested, if this instance arises, that you provide us with more than 24 hours notice. This will give the possibility for another person, who is waiting for an appointment, to be scheduled in your place. 
 
In view of our commitment to patient care, we would like to provide adequate appointment availability to our patients, in order to cater to their health needs and busy lifestyles. When cancellations are made with less than 24 hours’ notice, we are unable to offer that appointment to other patients. 
 
Appointments which are cancelled between 12-36  hours notification will incur a $39.00 cancellation fee. Patients cancel within 12 hours of appointment time or who do not show up for their appointment without calling to cancel (No Show) will incur a $85.00 cancellation fee.

Patients who arrive 18 minutes or more past their appointment time three(3)or more times in a 12 month period, may not be given priority for future appointments. Patients who do not arrive for their appointment without calling to cancel (No Show) may only rebook with management approval. 
 
The Cancellation and No Show fees are the sole responsibility of the patient and must be paid in full prior to, or on the patient’s next appointment. In unavoidable circumstances the fee can be waived although this is subject to Management approval. 
 
 
Thank you for understanding.  
 
 
Contact number for cancellations: Please text Anne Cusick L.Ac at 512-554-6642 as soon as you know you need to reschedule. 

ACU COLORADO HEALTH CARE ARBITRATION AGREEMENT

Between Patient Indicated Above and Anne Cusick L.Ac

 

Section 1. Submission of Claims to Binding Arbitration

In the event of any claim for damages arising out of:

injuries allegedly sustained by the Patient; or
the death of the Patient,
due to the alleged negligence, malpractice, or other unintentional wrongful act or omission of the Health Care Provider or their employees, such claim shall be submitted to binding arbitration pursuant to this Agreement and the Colorado Uniform Arbitration Act, C.R.S. § 13-22-201 et seq.
This agreement does not apply to claims arising from intentional misconduct or criminal acts.

Section 2. Selection of Arbitrator(s)

Upon written notice of a demand for arbitration by either party, each party shall, within 15 days, appoint one arbitrator and notify the other party of the appointment. The two appointed arbitrators shall, within 15 additional days, select a neutral third arbitrator. If they cannot agree, either party may petition a Colorado district court of appropriate jurisdiction to appoint the third arbitrator pursuant to C.R.S. § 13-22-211.

All arbitration hearings shall be held within a reasonable time and take place in the county where the Health Care Provider maintains their practice, unless otherwise agreed.

Section 3. Arbitration Costs 

All costs and expenses of arbitration, including the arbitrator's fees, shall be equally divided between the parties, unless the arbitrators determine a different apportionment is more appropriate based on the circumstances of the case.

Section 4. Right to Cancel

This agreement may be revoked in writing by any party within 60 days of execution, or within 60 days of the Patient’s last treatment, whichever is later. To revoke, a written notice must be delivered by mail or in person. If not revoked, this agreement shall remain in effect for 20 years from the date of execution and must be renewed thereafter.

Section 5. Additional Parties

By mutual written consent, any third party (e.g., other providers or facilities involved in the care) may join this arbitration agreement and be bound by its terms. Said party must sign a written addendum affirming their participation.

Section 6. Employees Included

Employees, agents, contractors, and assistants of the Health Care Provider shall be considered as covered parties under this Arbitration Agreement. No party shall bring a separate legal action against the Health Care Provider for acts or omissions of their employees that fall within the scope of this agreement.

Section 7. Patient Rights Preserved

(a) Signing this agreement is not a prerequisite to receiving health care.
(b) This agreement does not waive any substantive rights afforded to the Patient under Colorado law.
(c) The Patient retains the right to representation by legal counsel, to present evidence, and to cross-examine witnesses during arbitration.
(d) This agreement is intended to comply with the Colorado Uniform Arbitration Act and shall not limit due process.

Section 8. Governing Law

This agreement shall be governed by and construed in accordance with the laws of the State of Colorado, specifically the Colorado Uniform Arbitration Act (C.R.S. § 13-22-201 et seq.).