NEW PATIENT INTAKE

OFFICE POLICIES

Medical Records Release - Should you need copies of your records or other documents including receipts and income tax-related documentation, please note the following in accordance with Florida Statutes, and is payable prior to receiving the copies.  For copies of records or reports, a minimum of ten (10) working days and not more than thirty (30) may be required to process your request. A completed and signed record release must be done before any records are released.

Forms & Reports - There will be a $25-$150 administrative fee for forms such as disability reports and letters of medical necessity. The fee will be determined based on the complexity of the document. Please allow seven (7) to twenty (20) days for these reports to be completed. We do not fill out disability forms at this facility.

Policy Regarding Minors - We love children at East Lake Acupuncture; however, due to safety and noise issues we ask that all children be left at home. For safety reasons, children are prohibited from waiting in a treatment room while parents/guardians receive treatment. Minors under 12 cannot be left unattended in the lobby, and cannot be left in the lobby or treatment room with a “babysitter”. Staff is prohibited from babysitting/watching children.

Family & Friends - With the exception of a parent accompanying a minor receiving treatment or a caretaker accompanying a disabled individual who requires their presence in the treatment room, or requires a translator, family and friends are asked to wait offsite whenever possible. Our lobby is small. Seating is reserved for patients.

Phones- This is a place of calm and quiet. Cell phone use in common areas is prohibited. Please step outside if you need to make or take a call. Phone use during treatment is prohibited for safety and noise purposes. Please use headphones if watching videos or listening to your own music. 

Refunds - Refunds on products will only be offered if they are returned within fourteen (14) days of the date of purchase and are unopened, with the seal still intact. There are no refunds on services rendered, injections given, or opened products for any reason. There are no refunds or exchanges on rendered services or procedures, including injections. No exceptions. 

Appointment Deposits: Due to the high demand and limited availability of new patient appointments, we require a $50 deposit is required to hold all new patient appointments.  Deposits will be applied to the cost of the visit or held on account to cover fees, copays, co-insurance, or purchases. We do not require a new patient deposit for veterans booked through the VA. We require two business days (48 hours) notice to cancel or reschedule the visit. 

No-Show/Late Cancellation Policy (does not apply to VA patients) A $50 deposit is required to hold new patient visits (does not apply to VA referrals). If a new patient appointment is missed or not canceled with 48 hours prior notice to the scheduled time, the $50.00 fee is forfeited. If an established patient appointment is missed or not canceled with 24 hours prior notice to the scheduled time, a fee of $35.00 for acupuncture and medical services applies. Massage therapy: The full price of the service will be charged for massage therapy. All “no-show” or “late cancellation” fees are to be paid in full on or before the next visit and are subject to collections. Insurance will not reimburse the patient for this charge, nor will we bill your insurance for the missed visit. Our office staff makes appointment confirmation by text as a courtesy, though it is the patient’s responsibility to remember his/her appointment date and time. Patients with a history of missed appointments or late cancellations may be required to pay a deposit to hold future appointments or may be limited to same-day appointments only. No-show/late cancellation fees do not apply to veterans booked through the VA. 

Non-Discrimination: Admission to our clinic is non-discriminatory for services rendered, regardless of race, color, sexual orientation, nationality, political affiliation, disability, or age. All patients who come to our clinic for services are protected against discrimination assured by Title VI of the Civil Rights Act of 1964. Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975.

Insurance: As a courtesy, we will do our best to pre-verify your coverage and bill your insurance for the services provided during your visit(s); however, it is your responsibility to know your policy benefits and limitations. Our billing agent is available to answer questions you may have regarding our billing procedures. Please be aware that costs for each session may vary, depending on the procedures performed. A quote of benefits and/or authorization does not guarantee a payment or verify eligibility. Payment of benefits is subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service.

Uninsured discounts. We recognize the significant financial burden medical expenses create for patients with limited or no healthcare coverage. We will offer uninsured patients a similar discount to the discount taken by our contracted insurance carriers. Please ask about our most current posted fee schedule, as fees are subject to change from time to time.

Collections: In compliance with relevant state and federal laws, and in accordance with the provisions outlined in this Billing and Collections Policy, East Lake Acupuncture may engage in collection activities—including extraordinary collection actions (ECAs)—to collect outstanding patient balances. Patients or their responsible parties are expected to pay their full liability for services rendered within thirty (30) days of receipt of their first bill or in accordance with a mutually agreed upon installment payment plan. In the event the account becomes delinquent and is turned over to a collection agency, there will be a $50.00 fee for each account that you are responsible for, as well as any actual collection, court, or attorney fees.

Responsibility for Personal Valuables: We do not provide facilities for the safekeeping of valuables and are not responsible for lost, stolen, or damaged personal items that you or anyone accompanying you may bring into the facility. Please monitor your belongings and be sure to take your belongings with you when you leave.

If you have any questions or concerns, please discuss them with us prior to signing. 

By my signature below, I certify that I have read and understand East Lake Acupuncuture's Office Policies, I and I agree to abide by these policies. 

INFORMED CONSENT FOR TREATMENT AND CARE

I hereby request and consent to the performance of acupuncture treatments and other Oriental Medicine, and/or CAM (complementary and alternative medicine) procedures on me (or on the patient named below, for whom I am legally responsible) by a licensed healthcare provider, acting within his/her scope of practice and licensure parameters.

I understand the methods of treatment may include but are not limited to, acupuncture, moxibustion, cupping, gua sha, electrical stimulation, Tui Na (Chinese Massage), manual therapies (myofascial and trigger point release, massage therapy, physical and rehabilitative medicine modalities, food therapy, nutritional and lifestyle counseling, injections of herbs, natural substances, vitamins and minerals, bloodletting, and Chinese herbal medicine. I have been given the opportunity to discuss the nature and purpose of my treatment, my treatment plan, and other procedures, contraindications and side effects with my provider and have been given handouts providing additional written materials containing details of various procedures.

Acupuncture, injections and therapeutic blood draws (bloodletting). Acupuncture is generally considered a safe method of treatment, but it may have side effects, including, but not limited to bruising, redness, swelling, itching, or numbness or tingling near the needling sites that may last a few days, with possible dizziness or fainting. Rare and unusual risks of acupuncture may include spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax) may occur with deep needling or injections. Like acupuncture, injections (trigger point, acupoint, intramuscular, or subcutaneous) and bloodletting could cause pain, post-procedure soreness, bruising, bleeding and/or an infection at the site.

I understand that the risk of infection is negligible when all needles are sterile, but anytime the skin is punctured or broken, there is the potential for infection. At East Lake Acupuncture we practice Clean Needle Technique. While we do occasionally administer intramuscular injections during Acupoint Injection Therapy (AIT), we typically avoid needling or injecting deep enough to cause organ damage or puncture, thereby creating an even safer experience. Bloodletting involves pricking the skin over a blood vessel using a sterile lancet or hypodermic needle. We do not prick arteries, varicose veins, or large distended veins.

Cupping and gua sha. I understand that cupping and gua sha therapies will leave bruise-like (‘hickey”) marks that will last several days to several weeks. These areas of discoloration are typically not painful, though there may be soreness at the site(s) and in the surrounding muscles. Itching during and immediately following cupping or gua sha is typical due to the stretching of the skin and fascia and opening of pores. Cupping and gua sha are medical procedures, not a novelty, and should be treated accordingly.

Your provider will determine which areas are most appropriate for treatment, which techniques or methods should be used, where how the treatment should be applied, the length of time the cups should remain on, and which cupping techniques (stationary, moving, etc.) or gua sha techniques to employ. These are not services in which the patient should expect to dictate the terms of the service such as in massage service.

On rare occasions, burns or blisters may occur with “fire cupping” which involved using an open flame to remove oxygen from glass cups. Blisters can occur both from the heat and from fluids being drawn to the surface by non-heated cups, and the presence of a blister is not necessarily an indication of a burn. Small blisters should be left alone to heal on their own, while larger blisters should be drained and dressed by the provider. In severe cases, you may be referred to an emergency room. Cupping treatments may be a “detoxifying” treatment process and as a result, some patients may feel nauseous or unwell following treatment. Drinking water and taking Vitamin C have been reported to quickly relieve the discomfort. Be sure to inform your provider prior to receiving cupping if you have difficulty feeling pain, hot, cold, or pressure. It is important that your provider be aware.

Herbs and supplements. The herbs and nutritional supplements (which are from plant, animal, and mineral sources and may contain tree nuts, shellfish, and other allergens) that may be recommended are generally considered safe, although some may be toxic in large doses, or interact with medication. I understand that some herbs or supplements may be inappropriate during pregnancy, while nursing, or while on blood thinners. Some possible side effects of taking herbs include allergic reactions, nausea, gas, stomachache, vomiting, diarrhea, rashes, hives, and tingling of the tongue. Herbs and supplements need to be consumed according to the instructions provided orally and/or in writing. The herbs may have an unpleasant smell or taste. I understand that some herbs or supplements could interact with other things I am taking, including medications, and I have been advised to check ingredients before consuming, using reputable, printed or online resources including, but not limited to: http://healthlibrary.brighamandwomens.org/Library/DrugReference/DrugInteraction/,  https://www.aafp.org/afp/2017/0715/p101.html, https://healthy.kaiserpermanente.org/health-wellness/natural-medicines (there are a number of reputable sources available online.

Side effects. I will immediately inform my provider of any unanticipated or unpleasant effects associated with the treatment or of the consumption of herbs and/or supplements. I will notify my provider if I am, or become pregnant.

I do not expect the provider(s) to be able to anticipate and explain all possible risks and complications, and I wish to rely on the provider(s) to exercise judgment during the course of the procedure which the provider believes, based on the facts then known, is in my best interests.

By my signature below, I certify that I have read, or have read to me, the above consent. I have also had the opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. 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. I have been provided with a copy of the handout, What to Expect Your First Visit, and made aware that additional information in the form of handouts and therapy-specific informed consent forms, wall posters, lobby brochures, and in blog articles and online at www.eastlakeacu.com.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Our Notice of Privacy Practices provides information about how East Lake Acupuncture may use and disclose your protected health information and when we need your written authorization to do so. This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

If you want a family member, friend, or companion to be able to make or change appointments, accompany you into the treatment room (restrictions apply), or discuss your care with your provider, you must complete this form, which is available at the front desk. A separate authorization is required for each designee.

Privacy Policy. All records are kept strictly confidential and are subject to HIPAA compliance and will not be shared with any outside establishment, individual, organization, or medical facilities without explicit written consent from the client (you) or the client’s legal guardian. Unless legally required by local, state, or federal subpoena, summons, or other court order. Copies of our detailed Privacy Policy are available upon request, on our website (https://tinyurl.com/3pxdea5d) and are posted near the front desk and are on the clipboards containing the new patient paperwork. You may request a copy via email by emailing us at info@eastlakeacu.com.

By my signature below, I certify that I been given the opportunity to review and request a copy of East Lake Acupuncture, LLC’s Notice of Privacy Practices and Office Policies (posted in the reception area & on intake clipboards) on the date indicated below.