Patient Intake Form

Dr. Marie Perkins, A.P. East West Healing Solutions 34876 US 19 N. Palm Harbor, FL 34684

Office Policies

After hour care:
Our office does not use an answering service, only voice mail and e-mail. Phone calls will be returned during regular office hours along with answering e-mails. If you feel that you need immediate attention, call 911 or proceed to the hospital emergency room nearest you.

Missed appointments:
Our office prides itself with individualized and caring medical services. Since we do not double, nor over book, you are being assigned between 30 and 90 minutes of the physician’s and/or therapists’ time. Not showing up or canceling within 24 hours of your appointment time results in expenses not recuperated related to the operation of this office not to mention, time not utilized helping patients in need of medical attention. You will be charged $55 for missing or canceling an appointment with less than 24 hours notice. Payment will have to be made prior to booking your next appointment. That is applicable whether you are paying privately for your services or not. Insurance companies will not pay for these charges. Any additional pre-scheduled appointments will be cancelled if we do not hear from you and payment is not made prior to the next appointment.

Insurance coverage:
We will verify coverage prior to your treatment. If for any reason we are unable to do so, you will be charged self-pay rates for each treatment until verification is obtained. Our fees are determined by the complexity of each case and the different services used during treatment. Any balance due for your treatment is your responsibility whether your insurance company pays or not. We cannot bill your insurance company unless you bring in all insurance information. Your insurance policy is a contract between you and your insurance company. We are not party to that contract. In the event you do not have coverage for treatments received or if your insurance company has not paid your account in full within 45 days, the balance of your account will be automatically billed to you. In signing this document, you are assigning to this office the benefits to which you are eligible to receive for care rendered in this office. Additionally, in signing this document you authorize the release of any information to any insurance company, adjustor or attorney that will assist in the payment of a claim.

Usual and Customary Rates (UCR):
Our practice is committed in providing the best treatment possible for our patients. We charge what is usual and customary for our area. Please be aware that some, and at times perhaps all, of the services provided may be “non- covered” services and not considered reasonable and necessary under the Medicare program and or by other medical insurance. You are responsible for payment in full regardless of any insurance company’s arbitrary determination of usual and customary rates.

I have read, or have had read to me, understand, and agree to the above office policies.
A photocopy of this form shall be considered as effective as the original.
Non-Surgical Orthopedics and East West Healing Solutions share only a common facility and a common purpose of providing quality care to every patient but are separate practices and not partners nor joint ventures.
East West Healing Solutions reserves the right to update prices, policies & forms as necessary without prior notice or written consent.

Dr. Marie Perkins, A.P.   East West Healing Solutions
34876 US 19 N
Palm Harbor, FL 34684 You can choose one of two methods of payment:
1) Paying at the time of service
Paying at time of service frees this office from time-consuming paperwork and tracking of filed insurance claims or extended delays in lawsuit cases, subsequently enabling us to make the following reductions to our Usual and Customary Rates. You can choose the member or the non-member rate. Membership cost is one-time $150.00 per year.   

Traditional Chinese Medicine;

Service	Non-Members	Gold Members	Savings as a member
First Traditional Acupuncture Treatment	$165.00	$140.25	$24.75
Repeat Traditional Acupuncture Treatment	$125.00	$106.25	$18.75
Cosmetic Acupuncture	$170.00	$144.50	$25.50
Herbal Consultation	$125.00	$106.25	$18.75
Repeat Herbal	$75.00	$63.75	$11.25

 

Manual Therapy;

Includes but not limited to Cranio-sacral Therapy, Neuro-muscular Therapy, Myofascial Release, Reflexology, Lymphatic Drainage, Trigger point, Stretching, Range of Motion, Energy Work, Cupping, Cold Laser.

Service	Non-Members	Gold Members	Savings as a member
15 minutes	$25.00	$21.25	$3.75
30 minutes	$50.00	$42.50	$7.50
45 minutes	$70.00	$59.50	$10.50
60 minutes	$90.00	$76.50	$13.50
90 minutes	$130.00	$110.50	$19.50

  2) Delayed payment   You can choose for our office to file claims directly to your major medical insurance company, personal injury insurance, worker’s compensation benefits or wait for a settlement thru a Letter of Protection (LOP). In that case, the cost of your treatments will be based on our Usual and Customary Rates and Allowed Charges. (Cost per 15 minutes)

Modality	Cost	Modality	Cost
99203 Intermediate Office Visit (30)	$150.00	97024 Diathermia	$25.00
99204 Comprehensive Office Visit (40)	$170.00	97010 Heat/ Cold Therapy (moxa)	$25.00
99211 Minimal established office visit (15)	$50.00	97016 Vasopneumatic (cupping)	$70.00
97810 Acupuncture 1st 15 minutes	$125.00	97140 Manual Therapy	$90.00
97811 Acupuncture 2nd 15 minutes	$125.00	97110 Therapeutic Exercises	$80.00
97813 Acupuncture w/E-stim 1st 15 mins	$125.00	97139 Laser Therapy	$80.00
97814 Acupuncture w/E-stim 2nd 15 mins	$125.00

East West Healing Solutions, 34786 US 19 N. Palm Harbor, FL 34684

Informed Consent for Acupuncture Treatment and Care

I hereby request and consent to the performance of Acupuncture and other Oriental Medicine procedures, including various modes of physiotherapy on me (or the patient named below, for whom I am legally responsible) by Dr. Marie Perkins, licensed acupuncturist.
I understand that methods or treatment may include and are not limited to Acupuncture, Manual Therapies (moxibustion, cupping, gua sha, E-Stim, cold laser) and Chinese Herbal Medicine. I have had the opportunity to discuss with Dr. Marie Perkins the nature and purpose of acupuncture treatments and other procedures.
Acupuncture has the effect to normalize physiological function, to modify the perception of pain and to treat certain diseases or dysfunctions of the body. I have been informed that Acupuncture is a safe method of treatment but that occasionally there may be some bruising or tingling near the sit of insertion that may last a few days. There have been very rare instances reported of fainting, infections, and scarring. Bruising also may appear after Cupping.
The herbs (which are from plants, animals, and mineral source) that have been recommended are traditionally considered safe in the practice of Chinese Medicine. I understand that some herbs may be inappropriate during pregnancy. If I experience any gastro- intestinal upset or allergies to the herbs, I will inform Dr. Perkins.
I do not expect Dr. Perkins to be able to anticipate and explain all risks and complications, and I wish to rely on her to exercise judgment during the course of the procedure based upon the facts then known.
I understand that the clinical and administrative staff may review my medical records and lab reports, but all my records will be kept confidential and will not be released without my written consent.

Informed Consent for Massage Treatment and Care

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
I have read, or have had read to me, understand, and agree with the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for future condition(s) for which I seek treatment.A photocopy of this form shall be considered as effective as the original.

Patient’s Statement of Privacy Rights

As a patient of this practice, you have the right to privacy of your personal health information and to know that such information shall be properly and securely maintained by this practice in accordance with our own policy and with the Health Information Accountability and portability Act of 1996 (HIPPA). HIPPA was enacted to give you, the patient of a health care provider and covered under a health insurance claim, more control over your health information, to set boundaries on the use and release of health records, establish appropriate safeguards that health care providers and others must achieve to protect the privacy of Personal Health Information and to hold violators accountable with the appropriate penalties for violation of the patient’s right to privacy.

As a patient of this practice:

• You are entitled to an individually delivered, written notification of your privacy rights at the time of your first visit to this practice. The document your reading is this notice.
• You are entitled to see your medical records.
• You are entitled to receive a copy of your medical records.
• You are entitled to make an amendment to your patient health information within those records.
• While the doctor has the right to deny inclusion of the amendments into a patient file, you have the right to disagree with the doctor’s refusal of such inclusion of the amendment of those records. If the doctor disagrees, he shall supply you a written notification of such disagreement.
• The doctor has the right to a rebuttal of the patient’s disagreement. Any time a file is sent out of the office must be included.
• You have the right to specify how access to your health information is restricted and from whom
• You have the right to indicate the method and or the phone numbers and or addresses to which the telephonic and written communications to you shall be forwarded.
• All covered entities under HIPPA such as this practice or other health care providers or business associates such billing companies or claims administrators as are designated by the HIPPA privacy rule and with whom this practice must work on your behalf from the standpoint of effective treatment or billing of medical services and administration of such services shall be part of the chain of trust under the applicable Business associate Agreements whenever applicable with those parties. This means that those parties are bound to maintain the same privacy and security of your health information as we are.
• No personal health information shall be given out to any entity not related to your treatment and the billing of medical services rendered without your written authorization.
• You are entitled to this practice’s best efforts to maintain the security of personal health information on your behalf inside and outside this office.
• This practice shall provide Personal Health Information to required parties on the basis of the minimum necessary standard release and so as to maintain the intent of HIPPA in establishing that standard.
• You have the right to inquire of this office and gain correct and appropriate answers to any questions regarding your privacy at any time consistent with those as covered by HIPPA.
• You have the right to contact the Department of Health and Human services, Office of Civil Rights, which administers HIPPA, with questions or to file a complaint at toll free 1-877-696- 6775 or e-mail via www.hhs/gov/ocr

I hereby acknowledge receipt of this office Statement of Privacy Rights, provided on my behalf and in accordance with law and have read and understand my rights to privacy and security of Personal Health Information as a patient of this practice.

ARBITRATION AGREEMENT

Article 1: Agreement to Arbitrate: lt 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.

Article 2: All Claims Must be Arbitrated: lt 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, will also be determined by submission to binding arbitration. lt 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 or preceptorship 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 consodium, wrongful death, emotional distress, injunctive relief, or punitive damages.

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 othenvise 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 pafties furlher 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: lf 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. lf 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 ARBITRATION AGREEMENT, 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 ARBITRATION AGREEMENT.

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 acupuntture 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 thO 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 cu[ping, 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). lnfection 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 lo 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 bcufuncture and other procedures, and have had an opporlunity 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.

ACUPUNCTURIST NAME: Dr. Marie Perkins

*To be completed in person upon first appointment.

I attest that I have read and completed all pages of the intake paperwork for East West Healing Solutions and agree to all information and responsibilities therein