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.  Chinese Medicine 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 Chinese Medicine and other procedures within the scope of the practice of chinese medicine 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 Chinese Herbal Medicine, nutritional counseling, phone consultations, telehealth, and telemedicine.  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 Chinese Medicine is generally a safe method of treatment, but, as with all types of healthcare interventions, there are some risks to care.

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 chinese medicine.  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.

Payment:

Your appointment is reserved for you.  To change, reschedule, or cancel an appointment, please call  at least two business days, 48 business hours, before your appointment time.  This gives us time  to fill your appointment.  If no one answers, please leave a message.  For Monday appointments, please call by Thursday.  For Tuesday appointments, please call by Friday.  

“Minimum 48 Hours Cancellation Policy:”  Because we have made preparations and staffing for  your appointment, we ask for at least two business days, 48 business hours notice to  reschedule or cancel your appointment.  With LESS THAN 24 BUSINESS HOURS, your credit  card will be charged for your appointment.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.  (Health Insurance Portability and Accountability Act – “HIPAA”)

Patient Rights and Uses and Disclosures of Health Information:

PERSONAL HEALTH INFORMATION DISCLOSURE:

In the course of your care as a patient at Stonington Natural Health Center, we may use or disclose personal or health related information about you in the following ways:

1. Your personal health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.

2. Your health care records, as well as your billing records, may be disclosed to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are or may be responsible for the payment of your services.

3. Your name and address, phone number, and your health care records may be used to contact you regarding appointment reminders, information about alternatives to your present care, Stonington Natural Health Center newsletters, or other health related information that may be of interest to you.  If you are not home to receive an appointment reminder, a message may be left on your answering machine or voicemail.  Further, you have the right to refuse to provide authorization for this office to contact you regarding these matters.  If you do not provide us with this authorization it will not affect the care provided to you, or the reimbursement avenues associated with your care.

PERMITTED OR REQUIRED TO USE OR DISCLOSE HEALTH INFORMATION WITHOUT YOUR CONSENT OR AUTHORIZATION:

UNDER federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in these following circumstances:

1.  If we are providing health care services to you based on the orders of another health care provider.

2.  If we provide health care services to you in an emergency.

3.  If there are substantial barriers to communicating with you, but in our professional judgment believe that you intend for us to provide care.

4.  If we are ordered by the courts or another appropriate agency.

ANY USE OR DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION, OTHER THAN OUTLINED ABOVE WILL ONLY BE MADE WITH YOUR WRITTEN AUTHORIZATION.

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 Herbal Consultations 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.