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Fax to: 972-393-4200 Email to: denise@points4health.com Points of Health & Herbal Medicine Denise Edmiston, L.Ac., LCSW 413 W. Bethel Rd., Suite 202 Coppell, Texas 75019 P-(972)506-8113 F(972)393-4200 Tax ID# 26-4522119 NPI# 1386971810 Insurance Benefit Verification Date: / / Patient Name: Male or Female DOB: Patient Address: City/State/Zip: Patient Phone Number: Primary Policy holder: Relationship: DOB: Insurance : Phone#: Policy ID#: Group#: General Complanint: ************************************************************************************************* Upon verification of your Acupuncture benefits, your insurance company has informed us that your In Network or Out of Network benefits are as follows: Effective Date: Deductible Individual: Amount met: Deductible Family: Amount met: Copay: or Co-insurance: Pre-Cert or Pre Auth Required? Calendar year or Plan year? Max Out of Pocket: Amount Met: Health Fund (HRA, HAS, Flex plan): Balance:$ LAc OK? Are these CPT codes covered? 99202 99203 99213 97810 97811 97026 Is there a separate copay for the office visit if billed at the same time as a treatment? Number of visits or dollars per year for Acupuncture: Used? THIS MEANS: At each visit you are responsible for $ until your deductible has been met (which is approximately visits). Thereafter you will be responsible for $ for the remaining visits for each year. OR: At each visit you are responsible for a co-payment of $ for a maximum of visits per year. I have read and understand my acupuncture benefits as explained to me. I also understand that this is strictly an estimate and not a guarantee of payment according to my insurance company. I authorize payment of medical benefits to Denise Edmiston for my treatments. I authorize the release of medical records or other information necessary for the processing of my claims. I understand that this office will bill my insurance company as a courtesy to me, and if for any reason the insurance company does not pay or cover the services, that I will be directly responsible for no more than $120.00 for the initial visit and $80.00 for any visits thereafter. Patient s Signature: Date: / / Verified By: Date: / / Spoke to : @

PATIENT NAME: ACUPUNCTURE INFORMED CONSENT TO TREAT 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, 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 be 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 have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involved the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, 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. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and 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 results are not guaranteed. 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. 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 my present condition and for any future condition(s) for which I seek treatment. Patient Signature (or Patient Representative) Date (Indicate relationship if signing for patient) Acupuncturist Signature Date Denise Edmiston, L.Ac Points for Health Acupuncture & Herbal Medicine 413 W. Bethel Rd., Suite 202 Coppell, TX 75019

Points for Health Acupuncture & Herbal Medicine HIPAA Acknowledgement and Appointment Reminders Form I acknowledge that I have been provided access to Points for Health Acupuncture & Herbal Medicine (PFH) Notice of Privacy Practices. I understand that I have the right to review the Notice of Privacy Practices prior to signing this document. I understand that PFH staff members may need to contact me with appointment reminders or information related to my treatments. If this contact is to be made by phone, and I am not at home, a message will be left on my answering machine or with anyone who answers the phone. Information stripped of any personal identifiers may also be used for research and educational purposes by PFH. By signing this form, I am giving PFH authorization to contact me with these reminders and to utilize my information for research and educational purposes. _ Patient Name (print) _ Patient Signature Date PFH Privacy Rep/Date Authorization for Release of Health Information (Optional) I,, hereby authorize Points for Health Acupuncture & Herbal Medicine the use or disclosure of my individually identifiable health information to the party(s) described below. I understand this authorization is voluntary. I understand 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. Persons/Organizations authorized to receive information: (please print) Patient s Signature Date

Points for Health Acupuncture & Herbal Medicine New Patient Information Welcome to Points for Health Acupuncture & Herbal Medicine. Please read our office policies and sign below. For All Clinic Appointments: Cancellation Policy: Treatments are by appointment, although walk-ins are occasionally accepted. If you find that you need to cancel an appointment, it is important that we receive 24-hour notice. This enables us to fill the time slot. We reserve the right to charge a fee equal to the cost of a scheduled appointment for an appointment canceled with less than 24-hour notice or for a no show appointment. Payment for Clinic Services Rendered: Payment is due at the time of service and may be paid by cash, check or all major credit cards. Any checks returned due to insufficient funds will be charged an additional $30 by this clinic. If your medical insurance provides payment for acupuncture treatment, please bring your medical insurance card and driver license to your first appointment. We will verify your benefits within 48 hours. Payment for treatment is nevertheless required at the time of service until otherwise notified. Herbal Prescriptions: All herb sales are final. Points for Health Acupuncture & Herbal Medicine is not able to offer refunds on herbal products. Herbal prescriptions are intended only for the patient for whom they have been prescribed. Thank you for allowing us to provide you with quality health care. Patient s Signature Date

Points for Health Acupuncture & Herbal Medicine Notification Form Regarding Evaluation of Patient by Physician In the state of Texas, acupuncture and Oriental medicine is not considered "primary health care". As a result, Points for Health Acupuncture & Herbal Medicine is required to have you respond to the following statements before you may be treated. Please be advised that we will not be permitted to treat you with acupuncture if your response to all of these statements is no. Pursuant to the requirements of 22 TAC 183.7 of the Texas State Board of Acupuncture Examiners rules relating to Scope of Practice and Tex. Occ. Code Ann., 205.351, governing the practice of acupuncture. I (patient's name) am notifying the practitioners of Points for Health Acupuncture & Herbal Medicine of the following: I have been evaluated by a physician or dentist for the condition being treated within 12 months before the acupuncture was performed. I recognize that I should be evaluated by a physician or dentist for the condition being treated by the acupuncturist. Yes No OR I have received a referral from my chiropractor within the last 30 days for acupuncture. After being referred by a chiropractor, if after two months or 20 treatments, whichever comes first, no substantial improvement occurs in the condition being treated, I understand that the acupuncturist is required to refer me to a physician. Yes No It is my responsibility and choice whether to follow this advice. OR I have not been evaluated by a physician or dentist for the condition being treated, nor have I received a referral from a chiropractor, but I seek treatment for symptoms related to one or more of the following conditions: Chronic pain Smoking addiction Weight loss Alcoholism Substance abuse Patient s Signature Date Points for Health Acupuncture & Herbal Medicine is not responsible for untrue statements made by patients.

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