Patient Information

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Name Date
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Email Date of Birth Sex: M F
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Address/City/Zip
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Main Phone Alternate Phone
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Physician's Name Physician's Phone #
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Current Prescription Medications
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Current Over the Counter Medications
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Current Herbs/Nutritional Supplements
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Reason for visit today
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Other concerns
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How did you hear about us?

CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR

TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS
I understand that as part of my healthcare, this organization originates and maintains health records describing my health
history, symptoms, examination and test results, diagnoses, treatment and any plans for future care of treatment. I
understand that this information serves as:
❖ A basis for planning my care and treatment.
❖ A means of communication among the healthcare professionals who contribute to my care.
❖ A source of information for applying my diagnosis and treatment information to my bill.
❖ A means by which a third-party payer can verify that services billed were actually provided.
❖ A tool for routine healthcare operations such as assessing care quality and reviewing the
competence of healthcare professionals.
I understand that I have the right:
❖ To object to the use of my health information for directory purposes.
❖ To request restrictions as to how my health information may be used or disclosed to carry out treatment,
payment or healthcare operations – and that the organization is not required to agree to the restrictions
requested.
❖ To revoke this consent in writing, except to the extent that the organization has already taken action in
reliance thereupon.
I acknowledge that I have received a copy of the Privacy Policy
(optional) I request the following restrictions to the use of disclosure of my health information:

X_______________________________ ____________
Patient Signature or Legal Representative Date
Cancellation Policy – 24 Hour Notice Required
Our mission is to help as many people as possible while offering the highest level of
care possible. With respect to these intentions, we require 24 hours notice in
advance of an appointment if it is necessary to cancel or reschedule. This allows
enough time to contact other patients and fulfill their desire and need for this
appointment time.
All appointments that are cancelled or rescheduled with less than 24 hours notice,
and appointments missed without notice, will be charged a $40 cancellation fee.
Thank you for your understanding.
Patient Signature:_________________________________ Date:____________________

Printed Name:__________________________________

Regarding Insurance Coverage

I understand and agree that health and accident insurance policies are an arrangement
between an insurance carrier and myself. Furthermore, I understand that as a courtesy, the
Acupuncturist’s office will provide third party verification of benefits and insurance
billing. Verification of benefits is not guaranteed to be accurate and it is ultimately my
responsibility to determine if and how their coverage may apply. Any amount paid
directly to the Acupuncturist’s office will be credited to my account as dictated in the
network contract, as applicable. I clearly understand and agree that all services rendered
me are charged directly to me and that I am personally responsible for payment. I also
understand that if I suspend or terminate services, any outstanding fees for professional
services rendered me will be immediately due and payable.

I hereby authorize the Acupuncturist to treat my condition as s/he deems appropriate. I

also agree that I am responsible for all bills incurred at this office.

Patient’s Signature___________________________________ Date_____________

Parent/Guardian Signature ______________________ Date____________(If patient is a minor)

Policy Carrier:______________________________ Policy Number:_______________________________

Policy Phone # (provider services):____________________________