White Lily Acupuncture 10591 165 th St W Lakeville, MN 55044 (952) 892-5511 Notice of Privacy Policy White Lily Acupuncture is committed to providing exceptional care including the protection of your privacy and health information. This Notice of Privacy Policy describes how your personal and health information will be obtained and disclosed. Please sign the Patient Agreement form, which includes your receipt of this notice as well as your acknowledgment of its purpose. This privacy policy will remain in effect until it is replaced, or amended by changes in law, with a current notice being available at your initial consultation, in the office, as well as on the website. Any letters, testimonials, correspondence and thank you notes sent in and provided to us by you, will become exclusive property of White Lily Acupuncture. White Lily Acupuncture respects your right to privacy and we assure you no identifying information that you give us will ever be used publicly without your direct or indirect consent. How White Lily Acupuncture obtains and maintains your personal and health information: Information provided to us by you. Information about your financial transactions with us (billing transactions). From health care providers, insurance companies, workman's compensation, your employer, and other third party administrators (e.g. requests for medical records, claim payment information.) How White Lily Acupuncture uses your personal and health information: We may use information provided for managing health care treatments and services within the office. We may use information provided to collect payment from you, from an insurance company, worker s compensation, or a third party for services we provide. We may use information provided to take care of certain office and business tasks, such as contacting you regarding appointments and treatments, and correspondence with you regarding these matters. With your written consent, we may disclose health information about you to other health care professionals, family or friends that relate directly to your care. Patient Rights: You have the right to receive all notices in writing. Upon written request, you have the right to review and receive copies of your health care records. Upon written request, you have the right to receive a list of disclosures about your health care information this office has used. Upon written request, and as permitted by law, you have the right to request restrictions on the use and disclosures of your Protected Health Information. Upon written request, and as permitted by law, you have the right to request that we amend your Protected Health Information. You have the right to ask questions or file a complaint about our privacy policy, either with us or the Secretary of Health and Human Services. Page 1 of 9
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Patient Agreement Consent for Purposes of Treatment, Payment and Health Care Options I consent to the use or disclosure of my identifiable health information by White Lily Acupuncture for the purposes of diagnosis or providing treatment to, obtaining payment for my health care bills or to conduct health care options. I understand that diagnosis or treatment of me at White Lily Acupuncture may be conditioned upon my consent as evidenced by my signature of this document. I understand I have the right to request a restriction as to how my identifiable health information is used or disclosed to carry out treatment, payment or health care operations of the practice. White Lily Acupuncture is not required to agree to the restrictions that I may request. However, if White Lily Acupuncture agrees to a restriction that I request, the restriction is binding upon White Lily Acupuncture. I have the right to revoke this consent, in writing, at any time except to the extent that White Lily Acupuncture has taken action in reliance on this consent. My identifiable health information means health information, including my demographic information, collected from me and created or received by my practitioner, another health care provider, a health plan, my employer or a health care clearinghouse. This identifiable information relates to my past, present, or future physical condition and identifies me, or there is a reasonable basis to believe the information may identify me. I understand I have the right to review White Lily Acupuncture s Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my identifiable health information that will occur in my treatment, payment of my bills or in the performance of health care operations of White Lily Acupuncture. The Notice of Privacy Practices is also provided at the front desk and on the organizations web site at www.whitelilyacupuncture.com. This Notice of Privacy Practices also describes my rights and the duties of my practitioners with respect to my identifiable health information. White Lily Acupuncture reserves the right to change information contained in the Notice of Privacy Practices at any time. I may obtain a revised Notice of Privacy Practices by accessing the website or requesting the most current notice during any office visit. I understand that I am responsible for payment of services provided by White Lily Acupuncture, including out of pocket expenses, co-payments, deductibles and co-insurance. If acupuncture services and treatments are denied by the insurance company, no matter their reason, I understand I am responsible for the payment of all services and sessions in full, including rejected claims and future treatment sessions. I understand and agree to pay any invoices from the clinic within 30 days. If I arrive late for an appointment, the session will proceed for the remaining time of the scheduled appointment. If I fail to attend a scheduled appointment without notice, I will be expected to pay the full fee for that session, not billed to insurance, unless it is agreed that I was unable to attend due to circumstances beyond my control. Signature: Date: Page 3 of 9
Consent to receive Treatment By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Material Medica by a licensed acupuncturist Christine Keller, M.S. Dipl.O.M., L.Ac, and Nick Dougherty M.S., Dipl. Ac, L.Ac., at White Lily Acupuncture Clinic. I understand that acupuncturists practicing in the state of Minnesota are not primary care providers and that regular primary care by a licensed physician is an important choice that is strongly recommended by the clinic's practitioners. Acupuncture / Moxibustion: I understand that acupuncture is performed by the insertion of needles through the skin or by the application of heat to the skin (or both) at certain points on or near the surface of the body in an attempt to treat bodily disfunction or diseases, to modify or prevent pain perception, and to normalize the body's physiological functions. I am aware that certain adverse side effects may result. These could include, but are not limited to: local bruising, minor bleeding, fainting, pain or discomfort, and the possible aggravation of symptoms existing prior to acupuncture treatment. 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. Indirect Moxibustion: I understand that if I receive indirect moxibustion as part of therapy, there is risk of burning or scarring from its use. I understand that I may refuse this therapy. Chinese Herbs: I understand that the substances from the Oriental Materia Medica may be recommended to me to treat bodily disfunction or diseases, to modify or prevent pain perception, and to normalize the body's physiological functions. I understand that I am not required to take these substances but must follow the directions for administration and dosage if I do decide to take them. I am aware that certain adverse side effects may result from taking these substances. These could include, but are not limited to: changes in bowel movement, abdominal pain or discomfort, 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 White Lily Acupuncture as soon as possible. Acupressure/ Tui-Na/GuaSha/Cupping/Massage: I understand that I may also be given acupressure / tui-na massage/ gua sha scraping technique, cupping and or abdominal massage as part of my treatment to modify or prevent pain perception and to normalize the body's physiological functions. I am aware that certain adverse side effects may result from this treatment. This could include, but are not limited to: bruising, sore muscles or aches, and the possible aggravation of symptoms existing prior to treatment. I understand that I may stop the treatment if it s too uncomfortable. Electro-Acupuncture: I understand that I may be asked to have electro-acupuncture administered with the acupuncture. I am aware that certain adverse side effects may result. These may include, but are not limited to: electrical shock, pain or discomfort, and the possible aggravation of symptoms existing prior to treatment. If asked about administration, I agree to disclose if I have a pacemaker or any heart problems with the understanding that this may be very risky to my health and should opt for other treatment modalities. I understand that I may refuse this treatment. A Notice to Pregnant Women: I understand that I need to notify the practitioners at White Lily Acupuncture if I am or become pregnant while under their care. I understand that White Lily Acupuncture does not use labor-stimulating acupuncture points unless the treatment is specifically for the preparation of labor. A treatment intended to help endure labor requires a letter from a primary care provider authorizing or recommending such a treatment. If I am being treated for preparation of labor of my pregnancy, I understand this procedure is used to prepare my body for ripening and dilating my cervix to prepare for the start of labor. Due to this preparing effect, I understand that this may encourage the onset of labor. I specifically waive my right to any legal claim that may arise through this treatment. I agree to hold Christine Keller, M.S. Dipl.O.M., L.Ac, and Nick Dougherty M.S., Dipl. Ac, L.Ac.,. harmless for any and all complications that may occur to me or my child as a result of acupuncture for the preparation of labor. I understand that there may be other treatment alternatives, including treatment offered by a licensed physician. I am aware these modalities are not the substitute for medical care. I have carefully read and understand all of the above information and am fully aware of what I am signing. I understand that I may ask my practitioner for a more detailed explanation. I give my permission and consent to treatment. Signature: Date: Page 4 of 9
White Lily Acupuncture 10591 165 th Street West Lakeville, MN 55044 Fertility Patients Only Name: Today's Date: Address: City: State: Zip: Primary phone number: Cell/Secondary: Email address: Would you like to be included on our email newsletters? Y / N Date of Birth: Age: Weight: Height Marital Status: (circle one) M S W D Emergency Contact: Phone #: Relationship: Who may we thank for referring you? Have you received acupuncture before? Y N From who? Reason for today s visit: We are in network with Cigna and Health Partners insurance. Are you using insurance today? Have you checked your acupuncture benefits? # of approved visits: Company Policy # Group# Have you been evaluated by an OBGYN or REI? Yes No Have you had a diagnosis relating to infertility? Yes No Diagnosis (if any): Page 5 of 9
Do you have a pacemaker? Y N Do you have a bleeding disorder? Y N Are you or could you be pregnant? Y N Do you have any infectious diseases? Y N If yes, which ones? Please list all known food or drug allergies: Please list all medications including over the counter, and supplements you are currently taking: (You can use back of sheet if there is not enough room) Why? Why? Why? Why? Why? Hospitalizations and Surgeries: Page 6 of 9
Please indicate if you or any of your family members have been diagnosed with the following: ( Self: ( X ), Mother (M), Father (F), Sister (S), Brother (B), Grandmother (GM) Grandfather ( GF) and which side? GM-M (mother's) or GM-F (father's) Diabetes Migraines Aids / HIV Seizures Headaches Hepatitis Blood clots Chronic fatigue Tuberculosis Stroke Depression Cancer Heart Attack Anxiety Other: Hypertension IBS/Diverticulitis Hypo-tension Gastritis / Pancreatitis Anemia Constipation Arthritis Back Pain Asthma Tension HA Neck Pain Hypo/Hyperglycemia Ovulation: Do you have pain around or with ovulation? Yes No Do you track ovulation? Yes No (If yes, please circle) BBT / OPK / Other Do you experience breast tenderness around ovulation? Yes No Do you have fertile egg white consistency cervical fluid with ovulation? Yes No Premenstrual Syndrome: (Please circle any symptoms you experience before or during your period) Changes in appetite/cravings Looser stools Constipation Fluid rentention Breast tenderness Cramps Acne Headaches Changes in emotions Irritability Depression Other: Periods: Page 7 of 9
Age when menstruation began: When was your last period? How long is your cycle: (day 1 of period to day 1 of next period, ex: 24-32 days) Do you have an irregular cycle? In what way: Describe your flow: (Please circle) Heavy Light Moderate/Normal Consistency of blood: (Please circle) Watery/Thin Thick/Sticky Moderate/Normal Cramping: (Please circle) Severe Moderate Mild Before During After Clotting: (Please circle) Large Small Bright (red) Dark (brown, purple, black) What days of period do you have clotting: (ex: first day only) Spotting: (Please circle) Mid cycle Right before period After Bright red Dark Red Brown How many days of spotting do you experience: Have you ever been diagnosed with: (Please circle) Endometriosis Ovarian Cysts Polyps PCOS Uterine fibroids Pelvic adhesions Prolapsed uterus PID STD Other: Have you had fertility treatments? (IUI, IVF, ICSI) Yes No Month/Year Treatment Clinic Results Have you taken medication to help you ovulate? Yes No When? Have your fallopian tubes been evaluated medically?(hsg) Yes No Page 8 of 9
What were the results? Have you had any tubal operations? Yes No Have you had any hormone laboratory tests performed? Yes No What were the results? Do you have a single partner with whom you have been trying to conceive? Yes No Has he had a fertility workup? Yes No What were the results? Is your partner supportive of your wish to conceive? Yes No Have you taken oral contraceptives/ IUD? Yes No When? What kind? When did you stop? How long have you been trying to conceive? #Pregnancies: Ages of children: #Miscarriages: (dates, how far along in pregnancy): #Abortions: #D & C: COMMENTS / NOTES Page 9 of 9