Please input "N/A" for questions that do no apply to you.
Chief Complaint and Present Medical History
The purpose of this form is to understand your past and present medical history.
Tell Us About Your Past Medical History
Please select the frequency of use for the following:
Please check the following symptoms you currently or have previously experienced:
Skin and Hair
Pain Rating Scale
Your Family's Medical History
Request and Consent for Acupuncture
I hereby request and authorize licensed acupuncturist(s) of the Acupuncture Health Clinic to perform on me the treatment known as “Acupuncture” as his/her judgment may indicate, and further authorize him/her to use whatever therapeutic methods he/she see fit, regardless of whether these methods are commonly and generally accepted and practiced in this community.
I understand that acupuncture may include:
In the event that any unforeseen condition arises in the course of treatment, and in the judgment of the Acupuncturist it is advisable to use procedures in addition to or different than this now contemplated, I also request and authorize him/her to perform such treatments, use such procedures, or otherwise act in accordance with his/her professional opinion.
I understand acupuncture treatment to involve the use of needles, acupressure, moxibustion and electrical stimulation, etc. The risks, although limited, include puncturing organs in the abdomen or chest cavities. Acupuncture may affect people on all levels: physical, emotional, mental and spiritual, because it works with the whole body to create balance. The duration of treatment varies from person to person depending on the specific illness and their constitution. I fully understand that there is no stated or implied guarantee of success or effectiveness aftera specific treatment or a series of treatments.
Patient Financial Responsibility Form
I understand that I am fully liable for payment of expenses associated with the Student Intern and/or Acupuncturist's provision of acupuncture in accordance with my request and consent to receive treatment, and agree to pay or cause to be paid, in full, the amount billed for these services. If my conditions is such that treatment is beyond the normal capabilities of the Acupuncturist, I understand that I may be referred to other competent practitioners including, but not necessarily limited to, medical physicians or other practitioners. I also agree to give 24 hours' notice if I am unable to make scheduled appointment. I fully understand I may be charged the regular treatment fee ($30.00) if I miss an appointment without giving 24 hours' notice.
Medical Evaluation, Referral, or Recommendation
(Pursuant to the requirements of 22 T.A.C. 183.7 of the Texas State Board of Acupuncture Examiners’ rule (relating to Scope of Practice) and Tex. Occ. Code Ann. 205.351, governing the practice of acupuncture)
Notify the Acupuncturist of the following:
I have been evaluated by a physician or dentist for the condition being treated within 12 months before the acupuncture was performed. I recognized that I should be evaluated by a physician or dentist prior to being treated by the Acupuncturist.
I have received a referral from my chiropractor within the last 30 days for acupuncture.
Note: In the case of patients seeking treatment for smoking addiction, weight loss, alcoholism, chronic pain (defined as pain lasting longer than 6 months), or substance abuse, referral by a physician, dentist, or chiropractor is not required. After being referred by a chiropractor, if after 2 months or 20 treatments, whichever comes first, substantial improvements occurs in the condition being treated, / understand that the acupuncturist is required to refer me to a physician. It is my responsibility and choice
whether to follow this advice.
Patient’s Consent for the Purposes of Treatment, Payment and Healthcare Operations
I hereby give consent to Texas Health and Science University Intern Clinic the use and disclosure of my individual identifiable health information or Protected Health Information (PHI) for the following specific purposes:
“Protected Health Information” is any includes:
I understand I have the right to request a restriction on the use and disclosure of my Protected Health Information for the purposes of treatment, payment, or healthcare operations of the Clinic, but the Clinic is not required to agree to these restrictions. However, if the Clinic agree to a restriction that I request, the restriction is binding on the Clinic.
I understand I have the right to read and discuss the Notice of Privacy Policies and Procedures from this Clinic before I sign this consent form regarding the use and disclosure of my Protected Health Information.
I have the right to revoke this consent, in writing, at any time except to the extent that the acupuncturist or the Clinic has acted in reliance on this consent.
Your Information. Your Rights. Our Responsibilities.
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.
RightsYou have the right to:
Our Uses and Disclosures
We may use and share your information as we:
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.Get an electronic or paper copy of your medical record
Ask us to correct your medical record
Ask us how to do this.
Request confidential communications:
Ask us to limit what we use or share
Get a list of those with whom we’ve shared information
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
File a complaint if you feel your rights are violated
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
In these cases we never share your information unless you give us written permission:
How do we typically use or share your health information?We typically use or share your health information in the following ways.
Treat youWe can use your health information and share it with other professionals who are treating you.Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organizationWe can use and share your health information to run our practice, improve your care, and contact you whennecessary.Example: We use health information about you to manage your treatment and services.
Bill for your servicesWe can use and share your health information to bill and get payment from health plans or other entities.Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
Help with public health and safety issuesWe can share health information about you for certain situations such as:
Do researchWe can use or share your information for health research.
Comply with the lawWe will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Work with a medical examiner or funeral directorWe can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requestsWe can use or share health information about you:
Respond to lawsuits and legal actionsWe can share health information about you in response to a court or administrative order, or in response to a subpoena.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Changes to the Terms of this NoticeWe can change the terms of this notice, and the changes will apply to all the information we have about you. The new notice will be available upon request, in our office, and on our website.
Other Instructions for Notice
Acknowledgement of Reciept of Notice of Privacy Practices
I, First Name* Last Name* , have read reviewed, understand, and agree to the Notice of Privacy Policies for healthcare services in this office. This practice has attempted to provide each patient with a Notice of Privacy Policies.
Authorization for Release of Health Information
I, First Name* Last Name* , herby authorize Texas Health and Science University Intern Clinic the use or disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to received the information is not a health plan or healthcare provider, the released information mar no longer be protected by federal privacy regulations.
Attestation of Acupuncturist's Referral
(Optional form to be completed by the patient)
I, First Name Last Name , attest that the Acupuncturist/Student Intern has referred me to see a physician. It is my responsibility and choice whether to follow their advice.
Acupuncturist/Student Intern Signature: ______________________Date: ______________________