New & Returning Patient

Energy Matters uses HIPAA compliant applications for both email and texting. However, this protection is one-way and does not cover any data breaches on your end. Although unlikely, emails and texts you receive and send via the Internet may be intercepted by third parties. Hence, the privacy of emailed and texted health care data cannot be assured. Clients who choose to communicate via email and/or text messaging thus consent to an email and/or text exchange with the recognition that HIPAA-related privacy rights cannot be guaranteed.

Please note that email and/or texting are our primary modes of communicating scheduling and billing information to our clients. If you opt-out of receiving reminder emails/texts, we advise that you keep good track of your appointments as we do have late cancel/no show fees.

Billing: If for any reason you are unable to pay at the time of service, an invoice will be mailed to the mailing address you provided. All invoices are on net 15. If we do not receive your payment within 15 days of the due date, please be advised that we may charge you for the full fee for your treatment/service (you may ask for a copy of our most current Fee Schedule) and/or a 3% interest charge per month on all other unpaid items (herbs, supplements, custom herbs, class/event registrations, etc).

Emergency Contact

Sign up to receive our Energy Matters newsletters and get a 15% off discount on your next herb/supplement and/or retail purchase*. You’ll get 4 to 8 emails per month that focus on helping you live a healthier life with informative articles, special deals, and more. You can also choose to decline the offer below.

*You'll get a one-time, 15% discount off of a total purchase of herbs, supplements, and/or retail including food, face & body products, Qigong books and dvds. Not applicable for Multi-pure products, Microneedline, or Nanoneedling. Applies for in-person or via phone or email orders only. Discount cannot be applied to orders purchased through the Energy Matters Online Store (Marketplace). Energy Matters newsletters are sent through Mailchimp - a non-HIPAA compliant email and marketing platform. By agreeing to sign up for Energy Matters newsletters, you agree to share the following Personal Health Information: Full Name and Personal Email Address.

Payments Policy

Patients are responsible for paying fees at the time of service. We accept cash, check, all major credit cards, debit cards and HSA/FSA cards. There is a $20.00 service charge for returned checks.

Invoice payments are due upon receipt. 

Late Payment Warning
If you have received the Prompt Pay Discount for your services (see Fee Schedule*, p 1, col 2), and we do not receive your payment within 15 days of the due date, please be advised that we may charge you for the full fee for your treatment/service (see p 1, col 3).

Herbal products, supplements and skin care products may not be returned.

See *Fee Schedule Handout here: https://bit.ly/3euoIUn

By initialing below, you acknowledge receiving and understanding the Payments Policy.

Cancellation Policy

At Energy Matters, our mission is to return your body to the way it was meant to function every day, in full harmony and vitality. As a patient at Energy Matters, you are asked to agree to the following policies so that we can ensure the best possible health care experience for you while sustaining the livelihood of Energy Matters staff. We understand that life is complicated and unexpected things happen. Nonetheless, we require advanced notice for appointment cancellations and charge a fee for late cancellations and no shows. In addition, because another patient is likely to be scheduled after you, we may not be able to treat you if you arrive 15 or more minutes late for your appointment. Though we will do our best to work you in, if we cannot, this may result in a late cancel fee. See Late Fees on p2 here: https://bit.ly/emcancel

By initialing below, you acknowledge receiving and understanding the Cancellation Policy.

Informed Consent to Treat

Informed Consent to Treat

Acupuncture: I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named in this form, for whom I am legally responsible) by any and all licensed acupuncturists who now or in the future treat me while employed by, working or associated with Energy Matters Acupuncture and Qigong.

I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, sound helaing and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of herbs.

I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. 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, disposable needles and maintains a clean and safe environment.

I understand that while this document describes the major risks of treatment, other side effects and risks may occur. 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 that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue. I will notify a clinical staff member who is caring for me if I become pregnant.

While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgement during the course of treatment which the clinical staff thinks at the time, based upon the facts then know, is in my best interest. I understand that results are not guaranteed.

I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.

By voluntarily agreeing above, 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 condition(s) for which I seek treatment.

Bodywork: I understand that massage and bodywork (Deep Tissue, Shiatsu, Myofascial techniques, Craniosacral Therapy, lymphatic drainage, or other technique) provided by Ana Fletes and/or Kari Napoli of Energy Matters Acupuncture & Qigong is intended to enhance relaxation, reduce pain caused by muscle and other soft tissue tension or restrictions, increase range of motion, improve circulation, and offer a positive experience of touch.

The general benefits of massage bodywork, possible contraindications, and the treatment procedure have been explained to me. I understand that massage therapy and bodywork is not a substitute for medical treatment or medications and that it is recommended that I concurrently work with my primary caregiver for any condition I may have. I am aware that chiropractic spinal adjustments are not part of massage therapy.

• I have informed my massage therapist/bodywork practitioner of all my known physical conditions, medical conditions, and medications (including herbal remedies and supplements), and I will keep the practitioner updated on any changes that occur.
• I agree to obtain a medical release if required by my therapist for any specific health conditions.
• I realize that I have the right to refuse, modify, or terminate massage therapy or bodywork treatment at any time.
• I understand and agree that my practitioner has the right to terminate any session and refuse further treatment for inappropriate requests or suggestions of a sexual nature.

COVID-19
I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.

I understand that I am the decision-maker for my health care. Part of this office’s role is to provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.

To proceed with receiving care, I confirm and understand the following:

• I understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-to-person contact, in which COVID-19 can be transmitted.
• I understand that I am opting for an elective treatment that may not be urgent or medically necessary, and that I have the option to defer my treatment to a later date. However, while I understand the potential risks associated with receiving treatment during the COVID-19 pandemic, I agree to proceed with my desired treatment at this time.
• I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of procedures, I may have an elevated risk of contracting COVID-19 simply by being in a healthcare office.
• I am informed that you and your staff have implemented preventative measures intended to reduce the spread of COVID-19. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected with COVID-19 by proceeding with this treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment and give my express permission to you and the staff at your offices to proceed with providing care.
• I can download a copy of the Informed Consent to Treat here: https://bit.ly/emconsenttreat

I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I UNDERSTAND THAT I WILL HAVE AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE.

By initialing below, you acknowledge receiving and understanding the Informed Consent to Treat.

Notice of Privacy Practices

Energy Matters Acupuncture & Qigong, including staff, is required by law to maintain the privacy and confidentiality of your protected health information, and to provide patients with notice of our legal duties and privacy practices with respect to your protected health information. Protecting the privacy of your personal health information is important to us. This notice describes how information about you may be used and disclosed, and how you can access this information. Please read carefully.

Disclosure of your protected health information without authorization is strictly limited to defined situations including emergency care, standard health care operations, public health, research, and law enforcement activities. Any other disclosure for the purposes of treatment, payment, practice or operations will be made only after obtaining your consent. You may request restrictions on disclosures. Disclosures of protected health information are limited to the minimum necessary for the purpose of the disclosure. This provision does not apply to the transfer of medical records for treatment. You may inspect and receive copies of your records within 30 days of a request to do so. There may be a reasonable cost-based fee for photocopying, postage and preparation. You may request changes of your records. Our practice has the right to accept or deny your request. We maintain a history of protected health information disclosures that is accessible to you.

Energy Matters uses HIPAA compliant applications for both email and texting. However, this protection is one-way and does not cover any data breaches on your end. Although unlikely, emails and texts you receive and send via the Internet may be intercepted by third parties. Hence, the privacy of emailed and texted health care data cannot be assured. Clients who choose to communicate via email and/or text messaging thus consent to an email and/or text exchange with the recognition that HIPAA-related privacy rights cannot be guaranteed.

Our practice is required to abide by this notice. We have the right to change the notice in the future. Any revisions will be prominently displayed in our office. You may file a complaint about privacy violations by contacting us.

I have read the Privacy Notice and understand my rights contained in the notice. By way of my initials, I provide Energy Matters Acupuncture & Qigong with my authorization and consent to use and disclose my protected health care information for the purposes of treatment, payment, and health care operations as described above.

Policy on Health Insurance

Insurance Verification

We are in network with Cigna and are happy to help you verify if your particular Cigna plan has acupuncture coverage. If you do have acupuncture insurance, your fees will be in accordance with your policy. If you would like us to verify your Cigna insurance, please fill out this form online or call us at 510-597-9923.

Note - if your plan is not with Cigna, your insurance will not be verified. Starting in 2022, we are no longer filing claims for out-of-network plans and are happy to provide you with a superbill for you to self-file.

Health Insurance Policy

Energy Matters accepts many Cigna plans, workers’ compensation, and personal injury claims. We are happy to help you verify your level of insurance coverage. Once verified, we will submit your claims for reimbursement[1].

IN-NETWORK – BILLING
Patients who elect to have Energy Matters bill for them are accountable for any deductibles or out-of-pocket expenses, such as co-insurance/co-pays associated with each clinic visit. In addition, patients are responsible for all non-covered services, including herbs and supplements. Please note: our insurance rates differ from our "payment at the time of service" rates.

OUT OF NETWORK INSURANCE – REIMBURSEMENT
Some plans will cover acupuncture treatments. In these cases, after paying our “payment at the time of service” rates, we will provide all the required documentation you will need to submit claims for reimbursement of care.

WORKERS’ COMPENSATION
We must have your authorization letter and referral before we schedule you for your first appointment.

AUTO INSURANCE
We do not accept third-party claims or liens.

Insurance is very complicated and we, along with our insurance billing company, work very hard and do everything we can to ensure that you receive all the benefits of your plan. However, please note that you are ultimately responsible for any unpaid charges that may occur due to unforeseen complications that can sometimes happen when using insurance.

By signing below, I authorize payment of benefits to be made directly to Energy Matters Acupuncture and I understand I am responsible for charges not covered by this assignment. I also authorize the release of any information requested to process any claims.

Low Scent Environment

At Energy Matters, we are a ‘low-scent’ environment. We don’t use any cleaning products or personal care products with ‘fragrance’ in them, and ask our staff and patients to do the same.

When you come to our clinic, please help us create an environment for healing by avoiding scented and fragranced colognes, laundry detergent, dryer sheets, perfumes and body care products.

We do use products with essential oils, as they give scent without the side effects, and offer therapeutic benefits of their own. However, some people are sensitive to essential oils as well. If this is an issue for you, let us know so we can discuss options.

Please check symptoms you're experiencing or have experienced regularly in the past.