Informed Consent, Payment Policy, Treatment Terms and Conditions

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SECTION 1 - INFORMED CONSENT FOR TREATMENT

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 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, 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 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 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 involves 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.

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 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.

I consent for medical photographs to be taken of me by Constance Bradley, PhD, LAc. or a representative. I understand that the information may be used in my medical record, for purposes of medical teaching, or for publication in medical textbooks or journals. I hereby give Constance Bradley, PhD, LAc and staff the absolute right and permission to copyright and/or publish, or use photographic portraits of me, or in which I may be included in whole or in part, or reproductions thereof in color or otherwise, for presentations, photo albums, display on the company’s web site, art trade, news or any other lawful purpose whatsoever. I hereby waive any right that I may have to inspect and/or approve the finished product or the advertising copy that may be used in connection therewith, or the use to which it may be applied. By consenting to these medical photographs I understand that I will not receive payment from any party. Although these photographs will be used without identifying information such as my name, I understand that it is possible that someone may recognize me. Refusal to consent to photographs will in no way affect the medical care I will receive. If I wish to withdraw my consent in the future, I may do so with a written request.

By checking the box, it means I voluntarily agree to this treatment, 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. 

SECTION 2 - COVID-19 CONSENT

I understand that I am opting for an elective treatment that is not urgent and may not be medically necessary.

I also understand that the novel coronavirus, COVID-19, is contagious and is believed to spread by person-to-person contact; and, as a result. I recognize that Constance Bradley, PhD, LAc is closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19.

I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment, and I give my express permission for Constance Bradley, PhD, LAc to proceed with the same.

I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test.

I understand that possible exposure to COVID-19 before/during/after my treatment may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, and medical treatment at my own discretion.

I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the treatment itself.

I have been given the option to defer my treatment to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired treatment.

I agree to inform my provider:

  • If myself or anyone in my household participated in any travel within or outside of the US within the last 30 days.

  • If myself or anyone in my household has had close contact with a suspected or laboratory-confirmed COVID-19 patient in the past 2 weeks.

  • If I have tested positive for COVID-19.

  • If in the past 72 hours myself or anyone in my household has experienced a temperature of 99.5 or higher, sore throat, cough, shortness of breath, headache, repeated shaking chills, muscle pain, or new onset loss of taste or smell.

If I have experienced any of the parameters defined in the above bullets on this form or if my temperature at the time of appointment is 99.5 degrees or higher, I understand that my appointment may be canceled and rescheduled.

By checking the box, I am affirming that I understand the explanation above and have no more questions and consent to the treatment.

SECTION 3 - CANCELLATION AND PAYMENT POLICY

Cancellation Policy: You may cancel or reschedule an appointment with no charge at any time up to 24 hours before your appointment. An active credit card must remain on file with Dr. Constance Bradley Acupuncture to reserve an appointment. This card will only be charged in the event you miss or reschedule an appointment within 24 hours of the appointment time.

Cancellations, missed appointments, or rescheduling of an appointment to a different day within 24 hours of your appointment will incur a “late-cancel” fee of 50% of the scheduled service’s regular rate.

PLEASE NOTE: If you late cancel due to illness, you will not be charged the cancellation fee so long as you reschedule the cancelled appointment at the time of cancellation.

The following rules also apply:

If you arrive more than 15 minutes late for your appointment, we reserve the right to reschedule your appointment and charge you a late-cancel fee as described above.

If you incur more than three late-cancel fees within a 12-month period, we reserve the right to change your late fee to 100% of the scheduled service’s regular rate.

Non-Refundable Payment Policy: All services and products purchased are non-refundable. No refunds will be provided for the full or partial price for any unused services, packages or gift certificates purchased. I understand that I am responsible for full payment of my account and that payment is expected at the time of service. We accept credit cards, debit cards, and cash; Credit cards are subject to a 3% transaction fee. Insurance: We do not accept insurance; we accept FSA and HSA for applicable services. If needed, we can provide you with a “superbill” for services rendered that you can submit to your insurance company.

Clinic Etiquette: Please do not bring guests (unless they are your legal caretaker), children, or pets with you to your appointment.

By checking the box, I affirm that I am aware of and agree to the payment and cancellation policy.

SECTION 4 - ARBITRATION AGREEMENT

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by state and federal law, and not by a lawsuit or resort to court process, except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Further, the parties will not have the right to participate as a member of any class of claimants, and there shall be no authority for any dispute to be decided on a class action basis. An arbitration can only decide a dispute between the parties and may not consolidate or join the claims of other persons who have similar claims. Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, as to whether this agreement is unconscionable, and any procedural disputes, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the health care provider, including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers, preceptors, or interns who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the health care provider, including those working at the health care provider’s clinic or office or any other clinic or office whether signatories to this form or not. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care provider’s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages. This agreement is intended to create an open book account unless and until revoked. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days, and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party’s own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement. The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement. Article 4: General Provision: All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and, if not revoked, will govern all professional services received by the patient and all other disputes between the parties. Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

By checking the box, I affirm that I am aware of and agree to the arbitration policy.

SECTION 5 - PRIVACY POLICY SUMMARY

This notice summarizes how health data about you may be used and shared and how you can get access to this data. I. How we may use and share health data about you: a) Treatment - To give you medical treatment or other types of health services. b) Payment - To bill you or a third party for payment for services provided to you. c) Health Care Operations - For our own operations such as quality control, compliance monitoring, audit, employee review activities, licensing and conducting or arranging for other business activities. II. Disclosures where we do not have to give you a chance to agree or object: a) To you b) As required by federal, state, or local law c) If child abuse or neglect is suspected d) Public health risks (for public health activities to prevent and control spread of disease) e) Lawsuits and disputes (in response to a court or administrative order) f) Law enforcement (to help law enforcement officials respond to criminal activities) g) Coroners, medical examiners and funeral directors h) Organ or tissue donation facilities if you are an organ donor i) To avert a threat to an individual or to public health safety III. Disclosures where we have to give you a chance to agree or object: a) Patient directories - You can decide what health data, if any, you want to be listed in patient directories. b) Persons involved in your care or payment for your care - We may share your health data with a family member, a close friend, or other person that you have named as being involved with your health care. IV. Other uses of health data: Other uses not covered by this notice or the laws that apply to us will be made only with your written consent. V. You have the following rights relating to the health data we keep about you: a) Right to inspect your health record and to receive a copy of your health record upon request b) Right to amend information in your health record you believe is inaccurate or incomplete c) Right to know to whom we have disclosed your health information d) Right to ask for limits on the health information data we give out about you e) Right to receive communication from us about your health information in alternate ways f) Right to a paper copy of the complete Notice of Privacy Practices. Important Note: This notice does not include all of the details about our privacy policy. For more details, please request a a paper copy of the complete Notice of Privacy Practices.

By checking the box, I affirm that I am aware of and agree to the Privacy Policy.

SECTION 6 - COMPLETE NOTICE OF PRIVACY PRACTICES - FOR YOUR RECORDS

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.

Your Rights You have the right to: Get a copy of your paper or electronic medical record Correct your paper or electronic medical record Request confidential communication Ask us to limit the information we share Get a list of those with whom we’ve shared your information Get a copy of this privacy notice Choose someone to act for you File a complaint if you believe your privacy rights have been violated

Your Choices You have some choices in the way that we use and share information as we: Tell family and friends about your condition Provide disaster relief Include you in a hospital directory Provide mental health care Market our services and sell your information Raise funds

Our Uses and Disclosures We may use and share your information as we: Treat you Run our organization Bill for your services Help with public health and safety issues Do research Comply with the law Respond to organ and tissue donation requests Work with a medical examiner or funeral director Address workers’ compensation, law enforcement, and other government requests Respond to lawsuits and legal actions

Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct your medical record You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests. Ask us to limit what we use or share You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated You can complain if you feel we have violated your rights by contacting us using the information on page 1. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care Share information in a disaster relief situation Include your information in a hospital directory If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: Marketing purposes Sale of your information Most sharing of psychotherapy notes In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.

Bill for your services We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues We can share health information about you for certain situations such as: Preventing disease Helping with product recalls Reporting adverse reactions to medications Reporting suspected abuse, neglect, or domestic violence Preventing or reducing a serious threat to anyone’s health or safety Do research We can use or share your information for health research. Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests We can share health information about you with organ procurement organizations. Work with a medical examiner or funeral director We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: For workers’ compensation claims For law enforcement purposes or with a law enforcement official With health oversight agencies for activities authorized by law For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Other Instructions for Notice Effective date 01/01/2020 Privacy official contact: hello@constancebradley.com We never market or sell personal information.

By checking the box, I affirm that I have received an electronic copy of the Complete Notice of Privacy Practices.