I hereby request and consent to the performance of Acupuncture treatments and other Oriental Medicine procedures on me (or on the patient named below, for which I am legally responsible) by the below name licensed Acupuncturist. I understand that methods or treatments may include, but are not limited to acupuncture, homeopathic injection, moxibustion, cupping, bloodletting, electrical stimulation, tuina massage, guasha, Chinese or Western Herbal Medicine, nutritional counseling and/or supplementation. I have been informed that Acupuncture is a safe method of treatment, but occasionally there maybe some bruising or tingling near the needling sites that last a few days. There have been very rare instances reported of fainting, infection and scarring. There have been extremely rare instances of spontaneous miscarriage and pneumothorax. There may be some bruising after cupping, guasha and or after homeopathic injections. Also, there may be some bruising after the facial acupuncture treatment that last 1 – 2 weeks. I do not expect the acupuncturist to be able to anticipate all risks and complications. I wish to rely on the acupuncturist to exercise judgment during the course of the procedure which the acupuncturist feels at the time, based on the known facts.
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. I understand the same herbs may be inappropriate during pregnancy and will inform my practitioner immediately of pregnancy status. If I experience any gastro-intestinal reactions to the herbs I will inform the Acupuncturist immediately.
I have been informed that I have a right to refuse any form of treatment. I have read or have had read to me, the above consent. I have also had an opportunity to ask questions about its consent, and by signing below I agree to the above named procedures. I also understand there is always a possibility of an unexpected complication and I understand that no guarantee can be made concerning the results of treatment. 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 understand it may be necessary for my practitioner to contact one of my health care providers in order to coordinate medical treatment, to discuss any emergency situation and/or to share appropriate medical information. My signature give my practitioner permission to release my medical records for the reasons listed above. I agree to pay the full charge for any missed or forgotten appointments without 24-hour notice of cancellation. I agree to pay all charges incurred for services rendered, over and above insurance coverage.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry our treatments, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information that may identify you and that is related to your past, present or future physical or mental health or conditions and related health care services.
1.Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of your office that are involved in your care and treatment: for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Our protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health pan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities’, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by your name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary to contact to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include as Required By Law, Public Health issues as required by law. Communicable Diseases Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement Coroners, Funeral Directors, and Organ Donation Research, Criminal Activity, Military Activity and National Security Workers’ Compensation, Inmates, Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.
Other Permitted and Required Uses and Disclosure Will Be Made Only With Your Consent, Authorization of Opportunity to Object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure in the authorization.
Your Rights:
Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and your protected health information. Under federal law, however, you may not inspect or copy the records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative active or proceeding and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction of your protected information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved if your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.
You may have the right to receive an accounting of certain disclosures we have made, if any of your protected health information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. This notice was published and becomes effective on/or before April 14, 2003.
We are required by law to maintain the privacy of and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.
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