New Patient Intake & Waivers
Please fill out the following form to help us understand your physical condition, and the waivers below, which are required by state law for treatment.
ACUPUNCTURE INFORMED CONSENT TO TREAT
I understand that I am the decision maker for my health care. Part of this office's role is to provide me with information to assist me in making informed choices. This process is often referred to as "informed consent" and involves my understanding and agreement regarding the care recommended, the benefits and risks associated with the care, alternatives, and the potential effect on my health if I choose not to receive the care. Acupuncture is not intended to substitute for diagnosis or treatment by medical doctors or to be used as an alternative to necessary medical care. It is expected that you are under the care of a primary care physician or medical specialist, that pregnant patients are being managed by an appropriate healthcare professional, and that patients seeking adjunctive cancer support are under the care of an oncologist.
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 indicated 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 and in writing. The herbs may have 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 appreciate that it is not possible to consider every possible complication to care. I have been informed that acupuncture is a generally safe method of treatment, but, as with all types of healthcare interventions, there are some risks to care, including, but not limited to: bruising; numbness or tingling near the needling sites that may last a few days; and dizziness or fainting. Bums and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include 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.
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. I will notify a clinical staff member who is caring for me if I am, or become, pregnant or if I am nursing. Should I become pregnant, I will discontinue all herbs and supplements until I have consulted and received advice from my acupuncturist and/or obstetrician. Some possible side effects of taking herbs are: nausea; gas; stomachache; vomiting; liver or kidney damage; headache; diarrhea; rashes; hives; and tingling of the tongue.
While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, 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, as with all healthcare approaches, results are not guaranteed, and there is no promise to cure.
I understand that I must inform, and continue to fully inform, this office of any medical history, family history, medications, and/or supplements being taken currently (prescription and over the counter). 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.
I understand that there are treatment options available for my condition other than acupuncture procedures. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, I understand that I have the right to a second opinion and to secure other options about my circumstances and healthcare as I see fit.
By voluntarily signing below, I confirm 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 agree with the current or future recommendations for care. 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.
NOTIFICATION FORM REGARDING EVALUATION OF PATIENT BY PHYSICIAN
In the state of Texas, acupuncture and Traditional Chinese Medicine is not considered "primary health care". As a result, I am required to have you respond affirmatively to at least one of the following statements before you may be treated.
Please be advised that I will not be permitted to treat you with acupuncture if your response to all of these statements is no.
(Pursuant to the requirement of section 183.7(e) of the Texas State Board of Acupuncture Examiners' rules, section 6.11, Subsection (d) V.A.C.S. article 4495b, and Tex. 0cc. Code 205.301 governing the practice of acupuncture)
I, (patient's name listed as below), am notifying Connection Wellness of the following:
Or
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HIPPA Acknowledgement and Appointment Reminder Form
I acknowledge that I have been provided access to the Connection Wellness "Notice of Privacy Practices." I understand I have a right to review the "Notice of Privacy Practices" prior to signing this document.
I understand that Connection Wellness staff members may need to contact me with appointment reminders or information related to my treatment. If this contact is made by phone and I am not at home, a message will be left on my answering machine or with whomever answers the phone. By signing thisform, I authorize Connection Wellness to contact me with these reminders and information.
I also understand that my clinical information may be used for educational and/or research purposes by Connection Wellness or individuals authorized by Connection Wellness. All information that could be used to identify me personally (known as PHI) will be removed.
By signing this form, I authorize Connection Wellness to contact me, and am giving my informed consent for Connection Wellness to utilize my clinical information for research and/or educational purposes. I acknowledge that all information discussed during the assessment and treatment at Connection Wellness will be held confidential except in circumstances where my safety or the safety of others may be at risk.
I hereby authorize Connection Wellness the use or disclosure of my individually identifiable health information to the party(s) described on the following page under “Authorization of Personal Health Information.” I understand this authorization is voluntary. I understand that if the party(s) authorized to receive my information is/are not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.
I have been made aware that the HIPAA Privacy Rule requires all Covered Entities to have a signed Business Associate Agreement (BAA) with any Business Associate (BA) they hire that may come in contact with PHI. This is my acknowledgement that a BAA covers any online forms or waivers that I sign.
I will provide below information on any party(s) authorized to receive my information.
Authorization for Release of Health Information (Optional)
I, name listed as below, hereby authorize 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 party(s) authorized to receive my information is/are not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.
Office Policies
Cancellation Policy and Late Arrivals (15 minutes late or more) - Treatments are by appointment, although walk-ins are often able to be accommodated. If you find that you need to cancel an appointment, please call or email us as soon as you are aware you need to. We reserve the right to charge 75% of our fee if you cancel within 24 hours of your appointment. If the appointment is rescheduled for another time that same day and we can accommodate it, the fee is waived. Payment is due at the time of booking for house calls and upon arrival in the clinic.
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Payment for Clinic Services Rendered - Payment is due at the time of service at clinic and may be paid with a medical savings account card, flexible spending account card, health savings account card & all major credit cards. We do not accept cash, unless it is exact change. For house calls, payment is due upon booking. We are happy to provide you with a superbill so you may file with your insurance carrier.
Use of Media - We occasionally use pictures or video of patient progress on social media for marketing purposes. It is your choice as to whether or not you allow this. We will ask you for permission before taking pictures or video and you are encouraged consent or decline at that time, as well.
Notice of Privacy Policies
Our office is committed to providing service with respect for human dignity. Protecting your privacy and healthcare information is fundamental in the course of our relationship. This notice will remain in effect until it is replaced or amended by changes in law.
We gather personal information and health information in several ways:
• Information we receive from you.
• Information we receive from other healthcare providers.
• Information we receive from third party payers.
This information is used for treatment, payment and healthcare operations. You should be aware that during the course of our relationship with you we will likely use and disclose health information about you for treatment, payment, and healthcare operations. We will only use and/or disclose your protected health information when the law allows us to do so. Any other use and disclosures will be made only with your authorization and, in those instances; you have the right to revoke that authorization. And if so, that authorization would be honored, where legal to do so, from that date forward.
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Treatment: For example, from time to time, our practitioners may decide that it is medically necessary to refer you to a specialist for additional care. That practitioner will need your medical information in order to be able to treat you and that is why we send out your records.
Payment: Many of our patients utilize medical insurance that actually pays for their treatment. The insurers require your medical information to know how to pay us for your care and that is why we send out your records.
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Health Care Operations: We are allowed to disclose your medical information if that is necessary for our office to function efficiently. There are also times when we may need the help of a special vendor, such as a medical billing specialist, and we would then send your records to that vendor in order for us to carry on our business.
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You may specifically authorize us to use Protected Health Information (PHI) for any purpose or to disclose your health information by submitting the authorization in writing. Such disclosures will be made to any personal representation you choose to have your Protected
Health Information.
This office space has many practitioners. We reserve the right to share your file information within the confines of the professional and academic practices.
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Marketing
This office will not use your personal or health information for marketing communications without your written authorization. This office may send birthday cards, holiday cards, thank you cards, newsletters and appointment reminders, by phone calls, postcards or letters.
Disclosure
This office may use or disclose your Protected Health Information when required by law. This includes but is not limited to Public Health needs, Health Oversight requirements, and issues of abuse or neglect, and legal proceedings.
Patient Rights
Upon written request you have the right to access, review or receive copies of your healthcare records.
Exceptions are: 1) psychotherapy notes; 2) information we gather in preparation of an administrative action or proceeding; 3) data that is subject to certain provisions of the Clinical Laboratory Improvements Act. We may deny your request (in writing) under certain limited circumstances. Generally, if we agree to provide you with a copy of your records, we will do so within 15 days after you ask for it. We may charge you a reasonable, cost-based fee for the records.
Upon written request you have the right to receive a list of items this office disclosed about your healthcare information. We are required to give you that data except for any use or disclosure: 1) for treatment, payment and/or health care operations; 2) made with your authorization; 3) that we make to you; 4) for any national security or intelligence purposes; or 5) that does not require your authorization. We will provide this date for you (generally within 60 days) at no charge once each year, but after that, we will require that you pay a reasonable fee-based charge for the information.
You have the right to request that this office place additional restrictions on disclosure of your Protected Health Information. You may ask that we limit the use and disclosure of your protected health information; we are not required to accept your request. If we do agree, however, we will do as you wish except in an emergency. You may submit your request to us in writing and tell us: 1) what information you want us to limit 2) how you want us to limit that data and 3) to whom we are to limit the access to this data
You have the right to request that we amend your Protected Health Information; the request must be in writing. We have the right to deny that request if you ask about medical information that 1) was not created by any of our practitioners; 2) the information is not part of the medical or billing records; 3) is not part of the records you may access or 4) the medical information is accurate and complete. We may ask that you tell us, in writing, why you want us to amend your medical information. Generally, we must act upon your request within 60 days after receipt of your request. If we agree to your request, we must make the appropriate amendment and follow the law regarding how and whom we inform about this amendment. If we do not agree, then we will tell you our reasons. You then have additional rights, including an appeal (by someone who did not participate in the decision not to allow you to amend your record) and you have the right to submit a written statement of disagreement.
You have a right to receive all notices in writing.
You have the right to receive confidential communication by alternative means or at alternative locations.
Please make this request in writing to us. We will agree, so long as your request is reasonable, but you must tell us how to communicate with you and you must give us a complete address or contact information.
If you have questions, complaints or want more information contact:
NAME: Lindsey Wilder Flatt, Owner Connection Wellness
PHONE NUMBER: 512-378-0676
EMAIL: lindseywilderflattlac@gmail.com
You may also choose to send a written complaint to the U.S. Department of Health and Human Services.
This notice is effective as of April 7th, 2021. From time to time, we may revise our Notice. If we do, we will post the most current version in our office, and you make ask for a copy of the Notice at any time.
ARBITRATION AGREEMENT
Article 1:
Agreement to Arbitrate
: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as providedby state and federal law, and not by a lawsuit or resort to court process, except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Further, the parties will not have the right to participate as a member of any class of claimants, and there shall be no authority for any dispute to be decided on a class action basis. An arbitration can only decide a dispute between the parties and may not consolidate or join the claims of other persons who have similar claims.
Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, as to whether this agreement is unconscionable, and any procedural disputes, will also be determinedby submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the healthcare provider, including any heirs or past, present or future spouse(s) of the patient in relation to all claims, includingloss of consortium. This agreement is also intended to bind any children of the patient whetherborn or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the healthcare provider and/or other licensed healthcare providers, preceptors, or interns who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the healthcare provider, including those working at the healthcare provider's clinic or office or any other clinic or office whether signatories to this form or not.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the healthcare provider, and/or the healthcare provider's associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages. This agreement is intended to create an open book account unless and until revoked.
Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) and provide National Arbitration and Mediation ("NAM") with the party arbitrator's contact information within thirty days of the date Respondent files its initial responsive pleading. A third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties from a list of arbitrators supplied by National Arbitration and Mediation ("NAM") within thirty days thereafter. The list supplied by NAM shall be a list of between 5 and 10 arbitrators, depending upon availability. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party's equal share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party's own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damages upon written request to the neutral arbitrator.
The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement. The parties further agree that, where not in conflict with this agreement, the Healthcare Malpractice Dispute Resolution Rules and Procedures of NAM shall govern any arbitration conducted pursuant to this Arbitration Agreement. A copy of NAM rules are available on its website at https://www.namadr.com or by calling 1-800-358-2550to request a copy of the rules.
Article 4: General Provision: All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonablediligence.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the healthcare provider within 30 days of signature and, if not revoked, will govern all professional services received by the patient and all other disputes between the parties.
Article 6: Retroactive Effect: If patient intends this agreement to coverservices rendered before the date it is signed(for example, emergency treatment), patient should initial here. _ _ _ . Effective as of the date of first professional services.
If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.
Thank you for submitting, I look forward to seeing you soon!
