New Patient – Intake Form Acupuncture/ Herbal Medicine

The Health Insurance Portability and Accountability Act (HIPAA) went into effect on July 1, 1997. It protects an insured person's insurability. If a person has been insured for the past 12 months, a new insurance company cannot refuse to cover the person and cannot impose preexisting conditions or a waiting period before providing coverage.

Our office respects your right to privacy. Information regarding the reason you sought therapy with us is strictly confidential and is used to communicate with your doctor, case worker, and claims for payment from your insurer and the Dept. of Labor & Industrial Relations (for Workers' Comp claims) or for pre-authorization. Should any other official party request information about you, we would need to see your signed authorization to release information.

All other uses of the protected health information will be made only with your authorization and you have the right to revoke such authorization at any time. If a claim is unpaid due to the unavailability of the requested information, then you will be responsible for payment to us.

• Evaluation reports, treatment plans, copy of prescriptions for therapy and progress notes are generally mailed to the insurer (case worker) to carry out treatment and receive payment for services.
• In settlement cases, your attorney can request copies of your file with a written authorization from you. The other party's attorney will generally subpoena your records. A subpoena is a legal demand which we must comply with.
• All therapies are on an appointment basis. If you have questions regarding other alternatives, we can give you general information. Your primary care physician will determine what program for you to follow.

A patient/client may request restrictions on certain uses and disclosures of the protected information.

• You have the right to receive confidential communication of protected health information.
• You have the right to inspect and request a copy of protected health information & medical records.
• You have the right to amend protected information (there is an appeals process).
• You have the right to an accounting of disclosures of protected health information.

We reserve the right to change our privacy policy in accordance with HIPAA, and would send such notice to your last known address if your case is involved. Healthcare facilities must be in compliance with HIPAA following April 14, 2003 except in emergency treatment situations.

I have read and understand my rights regarding privacy of information and under which conditions this information is shared with others so that I may receive therapy and claims be made on my behalf (only for insurance purposes).