Patient, Parent or Guardian

To the best of my knowledge, the questions on this form have been accurately answered. It is my responsibility to inform the acupuncture clinic of any changes in medical status.

This office is in-network with CIGNA PPO. All other insurance clients will receive a superbill upon request. 

All fees for medical service are due at time of service. We accept cash, credit cards (incuding health savings cards), and personal checks.  All charges are due upon receipt. 

 Treatment Packages:
Packages are pre-paid discounted office visits to be used for treating any issues, or as needed for preventative care. All patients have a right to un-used funds should they choose to discontinue care. Please be aware that unfinished package visits will revert to the non-discounted rate and deducted from the final reimbursement. Please give 5-7 business days for refunds to be processed.

Release of Information:
By signing this form you are also authorizing this office upon request from your insurance carrier the release of any medical or other information necessary to process any claims.

For all other networks, a superbill will be provided if you have acupuncture coverage. Payment will otherwise be due at time of service. 

*As such, being in-network is not a guarantee of payment. Please take the time to review your own benefits and to understand your deductible, authorization requirements, and allowed number of treatments for acupuncture. Cigna PPO patients will be required to have a credit card on file. 

In accordance with the Federal Privacy Law (HIPAA), SPASM Acupuncture keeps medical information and records, and will only use them for patient treatment, health care operations, and billing purposes.

Treatment: The acupuncturist will use your medical information to give you the best possible care. 

Health Care Operation: SPASM Acupuncture will use this information for the appropriate follow-up care and/or patient notification. 

Billing Purposes: SPASM Acupuncture will use your medical information to bill the appropriate third party (if applicable) for your care. This may also include making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. 

Disclosure of Information with Extenuating Circumstances: 

• Health information will be given to family members in case of emergency or under other circumstances with proper authorization and documentation.
• Health information may be given to other physicians or institutions under emergency situations.
• Information may be given to proper authorities when neglect or abuse is alleged or suspected. 
• Information may be provided to courts or other agencies when a subpoena is given to this office. 

I understand and agree to the policy above

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me by the acupuncturist indicated below and/or licensed acupuncturists who now or in the future treat me while employed by, working or associated with, or serving as back-up for the acupuncturist named below. 

 
I understand that methods of treatment may include, but are not limited to acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant taste or smell. I will immediately notify a member of the clinical staff of any unanticipated or upleasant effects associated with the consumption of herbs. 

 
I have been informed that acupuncture is a generally a safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness, or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Rare risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment. 

 
I understand that while this document describes the major risks of treatment, other side effects may occur. 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, although some may be toxic in large doses. I understand that some of the herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, diarrhea, rash, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. 

 
While I do not expect the staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgement during the course of treatment which the clinical staff thinks at the time, based upon facts then known, is in my best interest. I understand the results are not guaranteed. 

 
I understand that the clinical and administrative staff may review my patient records and lab reports, but all of my records will be kept confidential and will not be released without my written consent. 

By signing below, I show that I have read, or have had read to me, the above consent to treatment. I intend this consent form to cover the entire course of treatment for my present condition and for future condition(s) for which I seek treatment.