DRY NEEDLING CONSENT AND NON-COVERED WAIVER FORM

Integrative Dry Needling involves placing a small needle into the tissue that is tender with the intent to normalize the physiology of the area and regain homeostasis, which will improve the function of the musculoskeletal system resulting in symptom reduction.

Integrative Dry Needling is a valuable treatment for musculoskeletal pain. Like any treatment, there are possible complications. While these complications are rare in occurrence and we take special care to avoid this type of issue, they are real and must be considered prior to giving consent to treatment.

Risk of the procedure:

Though unlikely, there are risks associated with the treatment. The most serious risk associated with Dry Needling is accidental puncture of the lung (pneumothorax If this were to occur, it may likely only require a chest x-ray and no future treatment. The symptoms of shortness of breath may last for several days to a week. A more severe lung puncture can require hospitalization and re-inflation of the lung. This is a rare complication and in skilled hands, should not be a concern.

Other risks may include bruising, infection, and nerve injury. Please notify your provider if you have any conditions that can be transferred by blood. Bruising is a common occurrence and should not be a concern unless you are taking a blood thinner. As needles are very small and do not have a cutting edge, the likelihood of any significant tissue trauma from Dry Needling is unlikely.

If you marked YES, please discuss this with your therapist.

 

How insurance pays:

Dry Needling is a non-covered procedure/treatment

Private insurance will only pay for services that it determines to be "reasonable and necessary" under section 1862 (a) (1) of Medicare law. If your insurance company determines that a particular service or treatment is "not reasonable and necessary" under Medicare program standards, then they will deny payment for that service or treatment unless explicitly stated that the service or treatment would be otherwise covered. Under these circumstances, these charges are the patient's responsibility.

• You may be charged, if your insurance does not cover this code(s) and applies to patient responsibility
• If you are only receiving Dry Needling (no physical therapy) then the cost will be the following: $100 for new patients which includes screen $50 for existing patients and/or additional treatment 

Patient Agreement:

I understand the risks of the procedure and that my insurance company does not cover the services listed above.

I agree to be fully responsible for any charges related to the services regardless of the insurance company's determination of benefits.