Mandatory Disclosure & Consent to Treat 

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24 hour notice is requested for change of appointment or cancellation, unless there is an emergency. A $77 fee will be charged for missed appointments or less than 24 notice cancellations.

Services: 

New patient acupuncture, discuss health history, goals and treatment plan: $120
Follow up acupuncture treatments: $85
Acupuncture + cupping: $111
Acupuncture + 15min sound therapy: $111
Cupping massage (no acupuncture): $88
Chinese herbs: varies

Treatment packages, 6 month expiration

Insurance: We do not bill insurance. Upon request, we will provide you with a receipt for your insurance company.

I hereby request and consent to the performance of the following on myself (or the patient named, for whom I am legally responsible) by Licensed Acupuncturist, Dr. Emily Blanche: acupuncture and other Eastern medical procedures including diagnostic techniques such as questioning, pulse evaluation, tongue evaluation, palpitation, observation, range of motion, muscle and orthopedic testing; modes of manual therapy such as Asian bodywork therapy (including: rocking, kneading, pushing, pulling, stretching, rhythmic striking, pressing, rolling, vibrating, grasping, etc…), cupping, moxibustion heat therapy, bleeding therapy, magnetic stimulation, the application of topical ointments, liniments and lotions; the prescription of herbal and homeopathic medicines as well as dietary supplements; dietary recommendations; exercise advice and healthy lifestyle recommendations.

Any suggested nutritional or dietary advice is not intended as treatment or therapy for any disease or symptom of disease. Nutritional counseling, supplement recommendations, and exercise considerations provided to me are to support the normal physiological processes of the body. I understand that any techniques, treatments, or lifestyle changes suggested should be undertaken only with the guidance of a licensed physician, therapist, or healthcare practitioner. 

I understand I have opportunities to discuss with my practitioner, or with other personnel, the nature and purpose of acupuncture and Eastern medical procedures, the methods of therapy, the techniques used, and the duration of therapy. Although I am aware that acupuncture and other procedures used in Eastern medicine have helped millions of people, I understand that no guarantee of cure or improvement in my condition is given or implied. I understand that I may seek a second opinion from another health care professional or may terminate therapy at any time.

I understand and am informed that, as in the practice of conventional Western medicine, in the practice of Eastern medicine there are some risks to treatment. I understand that although these risks are unlikely to occur, they are possible. I understand that these risks include, but are not limited to: bruising or pain or other strong sensation where the needle is inserted, or at location where bodywork, cupping (which will can leave marks go away between 1-4 weeks), or topical ointment/ lotion/ liniment is applied, or radiating from those locations; nerve pain, burns, aggravation of current symptoms, appearance of new symptoms and general aches. I do not expect the practitioners to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioners to exercise such judgment during the course of my treatment, as the practitioner feels at the time, based on the facts then known, to be in my best interest.

I understand that acupuncture and Eastern medicine treatments may not have the desired therapeutic effect when combined with excessive medication, alcohol consumption or illegal drug use at the time of treatment. If there is reasonable cause to believe that treatment is not appropriate for a patient who is under the influence of illegal drugs, alcohol, or appears to be overly medicated, then a treatment may not be performed at that time. In this case the patient will be informed that they may not be treated at that time and will be requested to reschedule their appointment.

I understand that acupuncture and Eastern medicine treatments may not have the desired therapeutic effect when the patient has not eaten properly before the time of treatment, and may result in dizziness, sweating, light headed feeling or other experiences similar to low blood sugar symptoms.

Dr. Emily Blanche L.Ac. complies with all rules and regulations promulgated by the Arizona Department of Public Health, including those related to the sterile use of needles in the practice of acupuncture and the sanitation of acupuncture offices.

I intend this form to cover the entire course of treatment for my condition and for any future condition(s) for which I seek treatment from Dr. Emily Blanche L.Ac.

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HIPAA Policy and Acknowledgment
Privacy Practices for Gold Lion Healing Arts
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Notice of Privacy Policies/HIPAA Compliance

The information provided below illustrates the manner in which your protected health information could be accessed and released and what you need to know about this process. This important document should be reviewed thoroughly. Managing the privacy of your protected health information is extremely important.

As mandated by Federal and State legal requirements, your protected health information must be protected. As part of these regulations, we are required to ensure you are aware of privacy policies, legal duties, and your rights to your protected health information. This notice of privacy policies, outlined below, will be in effect for the duration and will be followed by our practice. This notice will be in effect until it is replaced.

We reserve the right to modify our privacy policies and the terms of this notice at any time, and will make such modifications within the guidelines of the law. We reserve the right to make the modifications effective for all protected health information that we maintain, including protected health information we created or received before the changes were made. Changing the notice will precede all significant modifications. A copy of this notice will be provided upon request either digitally or printed.

Protected Health Information Use and Disclosure: Information regarding your health may be used and disclosed for the purpose of treatment, payment, and other healthcare operations. Examples cited below further explain the use and disclosure process.

Treatment: Use and disclosure of your protected health information may be provided to a physician or other healthcare provided providing treatment to you. However, this information will not be provided unless you have authorized it in writing.

Payment: Your protected health information may be used and disclosed to obtain payment for services we provided to you.

Healthcare Processes: We may use and disclose your protected healthcare information in relations with our healthcare process. These processes include an assessment, improvement activities, reviewing the competence or qualifications of healthcare professionals, provider performances and evaluating practitioner, conducting training programs, accreditation, certification, licensing, or credentialing activities.

Your Authorization: At any time, you may provide in writing your authorization for use and disclosure of your protected health information for any purpose. You may choose to revoke your written permission at any time. The revocation must be in writing. If you revoke your written authorization, it will not affect any use or disclosure prior to the revocation.

Your protected healthcare information may be used and disclosed to you, as described in the patient rights section of this notice. In addition, your protected health information may be used and disclosed to a family member, friend, or other person to the extent necessary to assist you with your healthcare, but only with your written authorization.

Person Involved In Care: In order to accommodate the notification of your location, your general condition, or death, your protected health information maybe used or disclosed to a family member, your personal representative, or another person responsible for your care. If you are present and wish to object to such disclosures of your protected health information, you may do so. To the extent you are incapacitated or emergency circumstances exist, we will disclose protected health information using our professional judgment disclosing only protected health information that is directly relevant to the person’s involvement in your healthcare. We will use our professional judgment and our experience with common practices to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of protected health information.

Marketing Health-Related Services: The use of your protected health information for the purpose of marketing communications is prohibited without your written authorization.

Required By Law: Your protected health information may be used or disclosed if required by law.

Abuse or Neglect: As required by law, if we have reason to believe that you are the victim of possible abuse, neglect, domestic violence, or other possible crimes, your protected health information may be disclosed to the appropriate authorities. If we have reason to believe the use or disclosure of your protected health information will prevent a serious threat to your health or safety or the health or safety of others we may have to provide the necessary protected health information.

National Security: Under some circumstances, the military may require disclosure of healthcare information for armed forces personnel. For the purpose of national security activities, counter intelligence and lawful intelligence, authorized federal authorities may require disclosure of protected health information. Protected healthcare information disclosure may be made to correctional facilities or law enforcement authorities with the lawful authority requiring custody of such information.

Appointment Reminders: Your protected healthcare information may be used to assist you with appointment reminders in the form of voicemail messages, postcards, or letters. We may also write a thank you card to whomever referred you to our practice. We will only do this with your written authorization. There is a form in your initial paperwork authorizing this. If you change your mind at any time, you may withdraw this authorization, but you must do so in writing.

Patient Rights

Access: At all times, you have the right to review your protected health information, with limited exceptions. At your request, we will provide your information in a format other than photocopies. If we are able to do so, we will accommodate your request.

Your request to obtain access to your information must be in writing. You may obtain a Protected Health Information Access Form by using the contact information at the end of this notice. We may need to charge you a reasonable cost-based fee for expenses including copies and staff time. You may also request access for submitting a letter using the information at the bottom of this notice. If you request copies, we will charge you $0.83 per page for the first 30 pages and $0.63 for every page after that plus $19.00 for staff time to locate and copy you protected health information. Postage will be included if you wish to have your information mailed. If you request a different format, we will charge a cost based fee for that format. An explanation of fees can be made available.

Restrictions: You may request that we apply additional restrictions to any disclosure of your healthcare information. We are not required to respond to the application of these additional restrictions. If we agree to follow your request regarding additional restrictions, we will follow the agreed restrictions unless an emergency situation dictates otherwise.

Alternative Communication: Your rights include the instruction to request how you are communicated to regarding your protected health information. Your request must be in writing and can spell out other ways or other locations regarding your protected health information communication. You must identify agreed upon explanations of payment arrangements under alternative communications.

Amendment: You can initiate a written request to amend your protected health information. Included in the amendment must be an explanation why information should be amended. Certain conditions may exist where we may reject your request.

Electronic Notice: If you receive a notice electronically, you are entitled to receive the notice in writing as well.

Questions and Complaints

If at any time you are unsure or concerned that your protected health information has not been protected or if you believe an error was made in the decision we made about accessing your protected health information; or in the response to a request you made to amend the use or disclosure of your protected health information; or to have us communicate to you by an alternative means or at an alternative location, you have the right to bring this issue forward. You may make a complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services at your request.

Privacy of your protected health information remains extremely important; we are committed to ensuring your privacy. 

We are available to assist you with any questions, concerns, or complaints.

The Right to Obtain a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice of privacy practices at any time by contacting our office 

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