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 the care recommended, the benefits and risks associated

with the care, alternatives, and the potential effect on my health if I choose not to receive the care. Acupuncture is not intended to substitute for diagnosis or treatment by medical doctors or to be used as an alternative to necessary medical care. It is expected that you are under the care of a primary care physician or medical specialist, that pregnant patients are being managed by an appropriate healthcare professional, and that patients seeking adjunctive cancer support are under the care of an oncologist.

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 below, for whom I am legally responsible)

including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.

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, and nutritional counseling. Iunderstand 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 anmember of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs.

I appreciate that it is not possible to consider every possible complication to care. I have been informed thatnacupuncture is a generally safe method of treatment, but, as with all types of healthcare interventions, there are some risks to care, including, but not limited to: bruising; numbness or tingling near the needling sites that maynlast 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 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 safenenvironment.

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. I will notify a clinical staff member who is caring for me if I am, or become, pregnant or if I am nursing. Should I become pregnant, I will discontinue all herbs and supplements until I have consulted and received advice from my acupuncturist and/or obstetrician. Some possible side effects of taking herbs are: nausea; gas; stomachache; vomiting; liver or kidney damage; headache; diarrhea; rashes; hives; and tingling of the tongue.

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 judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that, as with all healthcare approaches, results are not guaranteed, and there is no promise to cure.

I understand that there are treatment options available for my condition other than acupuncture procedures.

These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, I understand that I have the right to a second opinion and to secure other options about my circumstances and healthcare as I see fit.

Dear Patient,

Thank you for choosing Laura Acupuncture Clinic as your healthcare provider. We are committed to your treatment being successful, and our office policy has been established to ensure that the best health service can be provided to you and your family. Thank you for understanding our financial policy. Please let us know if you have any questions or concerns.

Full payment is due at the time of your service. We accept cash, check, credit and debit cards.

Missed Appointments and Cancellations

In order to prevent being charged a cancellation fee I agree to give at least 24 hrs notice of cancellation. When we make an appointment, I am reserving time just for you. Sufficient cancellation notice allows us to offer your time to another patient who may be waiting for an appointment. Uncanceled or missed appointments without 24 hr notice will be charged the full amount. For patients arriving more than 15 minutes late, you may be asked to reschedule your appointment if there is not sufficient time to provide the best treatment to you, or to have a shortened session. We will do our best to provide sufficient treatment, schedule permitting. Please help us provide the best care to you by keeping scheduled appointments in a timely manner. Late cancellations due to emergencies are understandable, in those cases the cancellation fee will be waived.

Regarding Insurance

Please remember that medical services are rendered to you, not to your insurance company. Check with your insurer to find out if acupuncture is included in your benefits. We are happy to verify your coverage for you after your first acupuncture session. Important: until we can verify your coverage, payment is due in full at the time of each visit. If you have insurance that covers acupuncture, we will do our best to determine what co-pay amount you are responsible for.

We will submit and process your insurance claims to receive partial payment. The full cost of services is ultimately your responsibility, even if your insurance provider denies payment for any portion of your bill for any reason. Some insurance companies send payments directly to the patient and in this case, we ask that you pay for services in full at the time of service. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under your medical insurance programs. Insurance companies do not reimburse for cancelled sessions. Please note that supplements and/or herbal formulas supplied as part of your treatment are not typically covered by insurance.

Our notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is uses or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The patient understands that:
·
 Protected health information may be disclosed or used for treatment, payment or health care operations

·  The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this notice
·  The Practice reserves the right to change the Notice of Privacy Policies
·
 The Patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions

·  The Patient may revoke this Consent in writing at any time and all future disclosures will then cease
·  The Practice may condition treatment upon the execution of this Consent

Authorization for other uses of Protected Health Information (PHI)

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you pursuant to our general Patient Consent Form. On occasion, the patient and the Practice may want to use PHI for reasons other than treatment, payment, and health care operations. This form summarizes the anticipated use of information about you for which this authorization is required. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Specific description of the information to be used or disclosed, including the specific purpose: Office promotions, holiday & or birthday cards, newsletters, change of address.
Individuals who may use or disclose this information.
Expiration date of this Authorization: Ongoing until patient indicates in writing otherwise.

The above mentioned protected health information may be subject to re-disclosure by the party receiving the information and my no longer be protected by the privacy rules.
By signing this form, you authorize the Practice to use and disclose protected health information about you for the reasons mentioned above. You have the right to revoke this authorization at any time, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior authorization. Submit your revocation to the Privacy Officer of the Practice.

By voluntarily signing below, I confirm that I have read, or have had read to me, all three notices which includes Acupuncture Informed Consent to Treat, Our Patient Care Financial Agreement Policy, and Privacy Rights HIPAA Notice and agreed to the terms and conditions.