PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S)
Assignment and Release (insured patients)
I certify that I (or my dependent) have insurance coverage with and I AUTHORIZE, REQUEST AND ASSIGN MY INSURANCE COMPANY TO PAY DIRECTLY TO THE PHYSICIAN/MEDICAL PRACTICE, INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary, including the diagnosis and the records of any exam or treatment rendered to me, in order to secure the payment of benefits. I authorize the use of this signature on all insurance claims, including electronic submissions.
What is your daily/weekly intake of the following:
I certify that the above questions were answered accurately. I understand that providing incorrect information can be dangerous to my health.
Informed Consent to Care
Natural Life Acupuncture and Kinesiology
A patient coming to the doctor gives him/her permission and authority to care for them in accordance with appropriate test, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare case, underlying physical defects, deformities or pathologies may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician. This office does not perform breast, pelvic, prostate, rectal, or full skin evaluations. These examinations should be performed by your family physician, GYN, and dermatologist to exclude cancers, abnormal skin lesions that should undergo biopsy/removal or other treatments.. We also do not prescribe or refill ANY controlled substances. All prescriptions should be refilled by your original prescriber and any new prescriptions should be issued by your primary care provider.
The patient assumes all responsibility/liability if the patient does not report on health forms any past medical history, illnesses, medicines, or allergies.
I agree to settle any claim or dispute I may against or with any of these persons or entities, whether related to the prescribed care or otherwise, will be resolved by binding arbitration under the current malpractice terms which can be obtained by written request.
Acupuncture care, like all forms of health care, while offering considerable benefit may also provide some level of risk. This level of risk is most often very minimal, yet in rare cases injury has been associated with acupuncture care. The types of complications that have been reported secondary to acupuncture care include bruising, bleeding, tingling, strong sensation at location of needle insertion. One of the rarest complications associated with acupuncture care is lung or organ puncture. I wish to rely on the doctors judgement based on the facts known at this time.
Prior to receiving acupuncture care in this office, a health history and physical examination will be completed. These procedures are performed to assess your specific condition, your overall health and, in particular, your whole body health. These procedures will assist us in determining if acupuncture care is needed, or if any further examinations or studies needed. In addition, they will help us determine if there is any reason to modify your care to provide you with a referral to another health care provider. All relevant findings will be reported to you along with a care plan.
This notice is effective as of the date it is signed and will expire seven years after the date on which you last received servies from us.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I have reviewed the Notice of Privacy Practices of Natural Life Acupuncture and Kinesiology.
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