INFORMED CONSENT FOR ACUPUNCTURE TREATMENT AND CARE

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, 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 massage, heating therapy, oriental 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 or/and in writing. The herbs may be an unpleasant smell or taste. I will immediately notify the acupuncturist of any unanticipated or unpleasant effects associated with the consumption of the herbs. I will not use the herbs as a replacement for any medications prescribed for me by a licensed physician.

Acupuncture normalizes physiological functions, modifies the perception of pain, and treats certain diseases or dysfunctions of the body. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, slight bleeding, fainting, temporary pain of discomfort at the site of treatment, and temporary aggravation of symptoms existing prior to treatment. 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 effect and risks may occur. I understand that no guarantees concerning its use and effects are given to me and that I am free to stop acupuncture treatment at any time.

 The herbs and herbal products (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Oriental 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 the possible aggravation of symptoms existing prior to herbal treatment.  Should I experience any problems, which I associate with these substances, I should suspend taking them and call the Acupuncturist as soon as possible.

I do not expect the Acupuncturist to anticipate and explain all risks and complications of treatment, and I wish to rely on the acupuncturist to exercise judgment during the course of treatment, which is in my best interest. I understand that results are not guaranteed. During and/or after acupuncture treatment, if there are new symptoms or conditions, or if my condition worsens, I will consult my physician for diagnosis and treatment. 

I also understand that I am recommended to bring my diagnosis or related medical records from my physician for the Acupuncturist to review in order to better understand my condition and symptoms. I agree that all personnel at the clinic may review my medical records and lab reports, and I understand that all materials will be kept confidential and will not be released without my written consent. 

I understand that payment is due when services are rendered regardless of existence of any insurance coverage or legal proceedings. 

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 present condition and for any future conditions for which I seek treatment.

 

____________________________________               _________________

^{Signature of Patient or Authorized Representative                                                              Date}

_____________________________________________________________

^{Printed Name and Relationship}

____________________________________               _________________

^{Signature of Acupuncturist                                                                                            Date}

 

 

Our Clinic Protects Your Health Information and Privacy

 

Dear Valued Patient,

 

This notice describes our office’s policy for how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected.

In order to maintain the level of service that you expect from our office, we may need to share limited personal medical and financial information with your insurance company¸ with Worker’s Compensation (and your employer as well in this instance), or with other medical practitioners that you authorize.

Safeguards in place at our office include:

·         Limited access to facilities where information is stored.

·         Policies and procedures for handling information.

·         Requirements for third parties to contractually comply with privacy laws.

·         All medical files and records (including email, regular mail, telephone, and faxes sent) are kept on permanent file.

Types of information that we gather and use:

In administering your health care, we gather and maintain information that may include non-public personal information.:

·         About your financial transactions with us (billing transactions).

·         From your medical history, treatment notes, all test results, and any letters, faxes, emails or telephone conversations to or from other health care practitioners.

·         From health care providers, insurance companies, workman’s comp and your employer, and other third part administrators (e.g. requests for medical records, claim payment information).

In certain states, you may be able to access and correct personal information we have collected about you, (information that can identify you - e.g. your name, address, Social Security number, etc.).

We value our relationship, and respect your right to privacy. If you have questions about our privacy guidelines, please call us during regular business hours at 617-773-3380.

 Yours truly,

 Bing Yang, Lic.Ac.

Mary’s Massage Therapy

423 Hancock street

North Quincy, MA 02171