I understand that I will be participating in a telehealth consultation with Kate Quinn Stewart, L.Ac., and that I will be provided services via an online or mobile phone experience. I understand that this is called “telehealth,” as I will not be in the same location as the person providing the services.

I understand that phone conversations and the video-conferencing platform(s) used by my provider are compliant with HIPAA regulations. I understand that health information shared or documented during telehealth services will be kept confidential.

I understand that there are risks to this use of technology including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth consultation if it is felt that the video-conferencing connections are not adequate for the situation.

 In case of technical difficulties with the video-conferencing platform, I am aware that I can:

·         Call my practitioner by phone at 703-520-7142

·         Email my practitioner at Kate@NurturingSpiritAcupuncture.com

·         Use the help or troubleshooting resources provided by the video-conferencing platform

I understand that there are two types of telehealth services offered by Nurturing Spirit Acupuncture.

 1)       "New Patient Virtual Intakes" are scheduled prior to new patient office visits and are for the purpose of sharing my health history, current health issues, and goals for change with treatment. Providing this information will help my acupuncturist design a treatment plan that is suited to my individual needs. 

2)      “Virtual Wellness Sessions,” will involve learning or being guided through various techniques and practices intended to help me support my own health and wellbeing. These may include self-acupressure, self-massage, qi gong (coordinated breath and movement practices), breath practices, relaxation techniques, guided imagery, suggestions for the therapeutic use of essential oils, dietary and lifestyle recommendations based on Chinese medicine principles, and/or Chinese herbal medicine consultation.

I understand that it is my responsibility to immediately inform my practitioner if I experience any pain, discomfort, or adverse effects during a telehealth session. I understand that if I am uncomfortable with any approach, technique, or practice used during a telehealth session, I have the right to ask the practitioner to modify or stop whatever is creating the discomfort. I understand that in the unlikely event that emergency circumstances arise during a telehealth session, my practitioner will advise that I seek urgent or emergency care that is local to me or that I call 911. I understand that telehealth services are not an appropriate medium for addressing emergency medical concerns.

I understand that care, treatment, and services provided by Kate Quinn Stewart via telehealth or in person are not a substitute for care, treatment, and services provided by a licensed physician.

 I understand that it is my responsibility to inform my practitioner about all aspects of my health, any medical conditions I may have, and any changes that occur in my condition either during the telehealth session or between sessions.

 I acknowledge that I am ultimately responsible for my own health and self-care.  Making healthy lifestyle choices can substantially support my health and wellbeing and will enhance the outcome of my virtual wellness sessions and/or acupuncture treatments. I understand that each individual responds uniquely and therefore my practitioner cannot guarantee the outcome of a virtual wellness session or use of the practices demonstrated therein.

 I understand that I will receive a bill for these telehealth services and I am responsible for payment regardless of my ability to obtain insurance reimbursement. Virtual wellness sessions will be billed separately. The fee for the virtual check-ins will be included in the fee for my in-person acupuncture visit.

 I affirm that:

·         I have read this form or had it read and/or explained to me.

·         I fully understand its contents, including the risks and benefits of telehealth services.

·         I have had the opportunity to ask questions and that my questions have been answered to my satisfaction.

·        By signing below, I hereby give consent to telehealth as an acceptable form of delivering healthcare services to me and that this consent will cover any and all of my sessions using telehealth services.

To sign this form, please draw your signature in the box either by using the mouse or trackpad on your computer, or by using your finger on the touchscreen of your phone or tablet.

Policies

Please initial in the provided spaces to acknowledge the following policies.

Appointments for virtual wellness sessions missed, cancelled, or rescheduled with less than 24 hours’ notice will incur a fee for the full cost of the appointment. If another patient can be found to fill the appointment, the missed appointment fee will not be charged.

In order to experience a more relaxing session, please silence your mobile phone and/or computer alerts and notifications.

In preparation for your session, please disinfect the computer equipment or mobile phone you will be using and wash your hands thoroughly, as your session may involve self-massage of acupressure points on the face.

If you move or change phone numbers, please inform me so that I am able to reach you in the event of unforeseen scheduling changes.

Nurturing Spirit Acupuncture does not submit insurance claims. A medical receipt can be provided, which you can submit directly to your insurance company for reimbursement. It is the patient’s responsibility to ascertain the terms under which the insurer will reimburse, and Nurturing Spirit Acupuncture makes no guarantees of reimbursement. Rules regarding whether telehealth services provided by an acupuncturist is covered, for how many treatments, and for what health conditions vary from one insurance plan to another and are at the discretion of the insurer.