Acupuncture Intake Form

INSURANCE INFORMATION

Primary Insurance

Secondary Insurance

I understand that this is a quotation of benefits and is NOT a guarantee of payment, and the agreement is between the Insurance Carrier and me. I authorize any and all payment from my insurance carrier directly to this office with the understanding that all monies be credit to my account upon receipt. Any denial of payment becomes my responsibility (patient).

Primary Health Concerns - List in order of concern to you

#1

#2

#3

#4

#5

List Of Injuries

(Falls, Sports Injuries, Repetitive Stress Injuries, Major Traumas) - 1

(Falls, Sports Injuries, Repetitive Stress Injuries, Major Traumas) - 2

(Falls, Sports Injuries, Repetitive Stress Injuries, Major Traumas) - 3

(Falls, Sports Injuries, Repetitive Stress Injuries, Major Traumas) - 4

(Falls, Sports Injuries, Repetitive Stress Injuries, Major Traumas) - 5

Have you been in any motor vehicle accidents?

Surgeries/Operations

Disease/Diagnosis

Have you ever received:

Personal Medical History

Lifestyle

Nutrition

Seattle Wellness Group

OFFICE POLICIES

At Seattle Wellness Group, we understand that life happens. If you need to reschedule an appointment please call or email us 24 hours in advance of the scheduled appointment time. We have a cancellation policy of $80 for any appointments cancelled or rescheduled within 24 hours. As a courtesy to your practitioner, please give advanced notice for rescheduling, as it is greatly appreciated.

CONSENT FOR RELEASE OF INFORMATION

Seattle Wellness Group respects your privacy. We understand that your personal health information (PHI) is very sensitive. We will not disclose your information to others unless you allow us to do so, or unless the law authorizes us to do so

Federal and state laws allow us to disclose your PHI for purposes of treatment and health care operations. State law requires us to get your written authorization to disclose this information for payment purposes.

I, authorize Seattle Wellness Group:

1. The release, use and disclosure of my PHI under HIPAA’s Privacy Rule to any and all of my health care providers to facilitate my health care and any and all of my insurance companies to facilitate the processing of my claims

2. To release any and all of my insurance/medical information to my spouse, significant other and/or family member(s).

3. To call me at any phone number I have provided to Seattle Wellness Group and leave a message at any of these phone numbers as necessary

FINANCIAL POLICIES & AGREEMENTS

I am solely responsible for the expenses of my care and/or the care of my dependents. While I may assign payment of benefits to Seattle Wellness Group, any uncovered services, deductibles, and co-payments are my financial obligation, to the extent allowed by terms of the Seattle Wellness Group’s provider contracts with insurance plans.

INSURANCE NON-COVERED SERVICE DISCLOSURE & AGREEMENT

1. Potential non-covered status include: the service is or may be deemed (a) investigational or experimental under the carrier’s internal guidelines; (b) not medically necessary under the carrier’s internal care or cost management guidelines; (c) not covered under the plan to which you are subscribed; (d) not provided in accordance with the Provider’s Agreement with the carrier or other requirements of the carrier’s or managed care entity’s internal guidelines.

2. The carrier authorizes the provider to charge the patient for the above services so long as this disclosure is made and signed by the patient prior to the services being provided.

3. I acknowledge that the Non-Covered status of the proposed service(s) has been explained and that a certain portion of my care may not be covered by or has not been authorized by my insurance plan. If any portion of the care provided is not, or may not be covered by insurance, then I shall be responsible for payment and shall make the necessary financial agreement with the healthcare provider to pay for these services.

AUTHORIZATION FOR TAKING AND RETAINING X-RAY FILMS

I hereby authorize the taking of analytical x-ray films by the doctors, clinic, and/or staff of Seattle Wellness Group, of such areas as may be of anatomical interest and which may be recommended from time to time by the doctor(s). 

Further I agree that the doctor(s)/clinic shall be the sole owner of such analytical films and shall remain in custody and in control of said films, until such time as I shall sign a Release Form stating otherwise that will be provided by Seattle Wellness Group upon request.

By signing below I, the patient, acknowledge that I have read the above statements regarding my care and treatment at Seattle

Wellness Group. This consent will remain in effect until revoked by me, the patient, in writing.

Acupuncture Informed Consent To Treat

I hereby request and consent to the performance of acupuncture treatments and other procedures within the

scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by

the acupuncturist named below and/or other 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, including those

working at the clinic or office listed below or any other office or clinic whether signatories to this form or not

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 in writing. The herbs may be an unpleasant smell or taste. I will immediately notify a member of the clinical

staff of any unanticipated or unpleasant effects associated with the consumption of the herbs.

I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side

effects, including bruising, numbness or tingling near the needing sites that may last a few days, and dizziness or

fainting. Bruising is a common side effect of cupping. Unusual 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.

Burns and/or scarring are a potential risk of moxibustion and cupping. I understand that while this document

describes the major risks of treatment, other side effects and risks 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 herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas,

stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff

member who is caring for me if I am or become pregnant.

I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of

treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the

clinical staff thinks at the time, based upon the facts then known is in my best interest. I understand that results

are not guaranteed.

I understand the clinical and administrative staff may review my patient records and lab reports, but all my records

will be kept confidential and will not be released without my written consent.

By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment,

have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to

ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for

any future condition(s) for which I seek treatment.