Please keep your healthcare practitioner aware of any changes to your personal information as soon as possible THANK YOU! Patient Info Printed Name: Address: DOB: / / Gender: Marital Status: S M D W Employer: Occupation: Contact Information Main Phone: I hate spam! We use your email address for the following purposes: appointment reminders, important clinic information, as well as to distribute coupons and events. Do you give your consent to use your email solely as a communication tool? Yes No Email address: Medical History Primary Care Physician: Phone Number: Last appointment? Emergency Contact Info Name: Relationship: Contact Number: How did you hear about us? Insurance Information Provider: Insurance ID Number: Group Number: Insurance Provider Phone Number: Named Insured: Relation to patient: If planning to use insurance, please present your insurance card(s) along with an ID so we can keep a copy on file and verify benefits.
Informed Consent (Page 1) By signing below and on page 2, I do hereby voluntarily consent to be treated with acupuncture, Oriental medical modalities and/or substances from the Oriental Materia Medica by practitioners at LoTurco Chiropractic Group PLLC (LCG). I understand that acupuncturists practicing in the state of Colorado are not primary care providers and that regular primary care by a licensed physician is an important choice that is strongly recommended by this 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 dysfunction 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. Direct or Indirect Moxibustion: I understand that if I receive direct or indirect moxibustion as part of therapy, there is a risk of burning or scarring from its use. I understand that I may refuse this therapy. Chinese Herbs: I understand that substances from the Oriental Materia Medica may be recommended to me to treat bodily dysfunction 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 LCG as soon as possible. Acupressure/Tui-Na: I understand that I may also be given acupressure/tui-na/shiatsu 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. These 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 is too uncomfortable. I have read and understand this Informed Consent (Page 1) document and I give my permission and consent to treatment.
Informed Consent (Page 2) Cupping/Guasha: I understand that I may also be given cupping/guasha 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. These 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 is 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. I understand that I may refuse this treatment. Acupoint Injection/Trigger Point/Prolotherapy (Bonepecking) Injection Therapy: I understand that there are risks involved in having any type of acupuncture and/or injection therapy, allergic reactions, bruising, punctured lung, nerve damage and irritation causing partial paralysis. Some injections may make you feel ill or experience post treatment pain or create a healing reaction that is unpleasant to experience. Allergic reactions can sometimes be very serious, and in some cases fatal. Allergic reactions are rare, but do happen. If you have allergies please inform LCG immediately. If you have allergies to dental anesthetics please inform your provider at LCG. Also, if you are on blood thinners please inform the provider at LCG. I understand that there may be other treatment alternatives, including treatment offered by a licensed physician. I understand that utilizing the services of LCG, participation in acupuncture, and related treatments is strictly voluntary and that I may discontinue services with LCG at any time. 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 have read and understand this Informed Consent document and I give my permission and consent to treatment. Cancellation Policy: If unable to keep an appointment, please give us 24 hours notice. IF YOU FAIL TO KEEP YOUR APPOINTMENT, OR CANCEL WITHin 24 HOURS OF IT, A $60 FEE WILL BE ASSESSED. THIS CHARGE IS NOT ELIGIBLE TO BE BILLED TO INSURANCE. I have read and understand this Informed Consent (Page 2) and Cancellation Policy document and I give my permission and consent to treatment.
CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care of treatment. I understand that this information serves as: A basis for planning my care and treatment. A means of communication among the many healthcare professionals who contribute to my care. A source of information for applying my diagnosis and surgical information to my bill. A means by which a third-party payer can verify that services billed were actually provided. Please note that this office submits insurance claims via electronic media and fax machine. If you are not comfortable with this, please notify us and we will use alternate methods. A tool for routine healthcare operations such as assessing care quality and reviewing the competence of healthcare professionals. I understand that I have the right: To object to the use of my health information for directory purposes. To request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that the organization is not required to agree to the restrictions requested. To revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereupon. I request the following restrictions to the use of disclosure of my health information: I have read and understand this document
COLORADO MANDATORY DISCLOSURE STATEMENT Education and Experience Mark VanOtterloo started his practice, Vital Balance Acupuncture in 2012. He completed his Doctorate in Acupuncture and Oriental Medicine from the Oregon College of Oriental Medicine in 2016. The Doctorate of Acupuncture and Oriental Medicine is a 2 year program. It includes 360 credit hours, a requirement of an established acupuncture clinic, and a published academic journal article. As well as 2 externships in prominent clinical settings, which he completed overseas in China and Taiwan. The Master s in Traditional Chinese Medicine program requires at least 2,850 hours of education including 615 hours of clinical acupuncture practice and over 180 hours of herbal medicine practice. Mark is a board member of the Acupuncture Association of Colorado and a licensed acupuncturist in Colorado. This license has never been suspended or revoked. This clinic complies with the rules and regulations promulgated by the Colorado Department of Health, including the proper cleaning and sterilization of needles and the sanitation of acupuncture offices. Only single-use, disposable, factory- New Patient Office Visit 2 Services Visit or Injection 1 Service 1 Service Visit Cash price $110.00 $75.00 $50.00 Description of services 20-45 minutes of contact time with the practitioner to create a report of findings, plan for treatment, insert acupuncture needles, and set up electrostimulation machine. 16-30 min of contact time with the practitioner to insert acupuncture needles and to set up electro-stimulation machine. This service may be used for established patients wanting a new acupuncture prescription for a series of acupuncture treatments. 7-15 min of contact time with the practitioner to insert acupuncture needles and set up electro-stimulation machine (if needed) Patient s Rights The patient is entitled to receive information about the methods of therapy, the techniques used, and the duration of therapy, if known. The patient may seek a second opinion from another healthcare professional or may terminate therapy at any time. In a professional relationship, sexual intimacy is never appropriate and should be reported to the Director of the Division of Registrations in the Department of Regulatory Agencies. The practice of acupuncture is regulated by the Director of Registrations, Colorado Department of Regulatory Agencies. If you have comments, questions, or complaints, contact the Acupuncturists Registration Office. Acupuncturist Registration Office 1560 Broadway, Suite 1350 - Denver, Colorado 80202 - (303) 894-2440 I have read and understand this document
FINANCIAL AGREEMENT HEALTH INSURANCE We would like to take a moment to welcome you to our office and to assure you that you will receive the very best care available for your condition. In order to familiarize yourself with the financial policy of this office, we would like to explain how your medical bills will be handled. Payment Arrangement Coverage for acupuncture services does not start until you have met your deductible. An interest charge of 1.5% per month may be applied to your past-due balance if they are not paid in a timely manner. This is the arrangement that has been verified with your insurance program as your benefits for the therapies within the scope of practice for a Licensed Acupuncturist. Assignment of Benefits Attn: BCBS and United Healthcare Out of Network Attached is an Assignment of Benefits form, which we would like you to sign. This form instructs your insurance company to send their payment directly to this office. If your insurance carrier sends you payment for services incurred in this office, you shall send or bring the full payment to our office immediately upon receipt. Please cash the insurance check and notify our insurance billing department. Then mail a copy of the Estimation of Benefits (EOB) form with a check for the payment amount. Make payments to the LoTurco Chiropractic Group and mail to: LoTurco Chiropractic Group 255 Union Blvd Ste 330 Lakewood CO 80228 Release of Information If your insurance company requires medical reports to document your treatment and progress, your signature below authorizes the release of medical information necessary to verify benefits and process your claims. We may communicate the following information through one or more of the following methods: in person, by phone, by fax, by us mail, by email. If you are not comfortable with these methods, please notify us and we will use alternate methods. Voluntary Termination of Care If you suspend or terminate your care at any time, your portions of all charge for professional services are immediately due and payable to this office. All services rendered by this office are charged directly to you, and you ultimately, will be personally responsible for payment, regardless of your insurance coverage. We hope that this answers any questions you might have concerning the financial policies of this office. Once again, we welcome you to our office, and will be glad to answer any further questions that you might have. I have read and agree to the above. Patient Signature Date