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.
Cancellations:As a courtesy to our office and other patients, we ask that you please notify the office at least 24 hours in advance if you need to cancel or reschedule your appointment. Visits cancelled at short notice will be charged at the larger of 50% of the current office visit fee. Frequent cancellations gives this office the right to refuse continued treatment.
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:
I understand and agree to the policy above