Iris Netzer, L.Ac. | Kim Schwartz-Finkelstein, L.Ac.
Marcy Gordon L.Ac.
201 East 56th St. NY, NY 10022
Patient Intake Form
First Name: Last Name:
Address: City: State:
Health Insurance Information
Please note: The information you are asked to provide is pertinent within the scope of Chinese Medicine. If you have any questions regarding any content on this intake form, feel free to ask or contact us and one of us will be happy to explain. Acupuncture Remedies respects your privacy and complies with HIPAA patient information requirements.
Your Health History
Have you ever had acupuncture?
If yes, when?
For what condition?
Are you currently under the care of a physician?
If so, who?
For what condition(s)?
Main reason(s) for seeking acupuncture:
How long have you experienced symptoms?
Your condition is improved by:
Your condition is aggravated by:
List all current medications, prescribed or over the counter:
List all current vitamins, herbs and other supplements:
Significant illnesses (please check all that apply)
Please list any surgeries you’ve had including dates:
Please list any allergies:
Please list any major emotional or physical traumas you’ve experienced:
Lifestyle (please check all that apply, and note frequency of use)
Do you exercise?
Please list types of activity and frequency:
How many meals per day?
How many snacks per day?
Head, Eyes, Ears, Nose and Throat
Emotional stress scale
1 2 3 4 5 6 7 8 9 10
(no stress) (moderate) (extremely stressed)
Rate your stress level regarding:
Age menses began:
Age menses ended (if applicable):
Date of last OB/GYN exam:
Hysterectomy? Partial Full Hormone replacement therapy
Headaches before menstrual cycle during cycle after cycle
Period lasts days. Usual number of days between periods
Flooding and tricking
Watery, thin and bright red
Stop and start flow
If you have been evaluated for infertility, what was your diagnosis?
Terms of Service
Acupuncture is NOT a substitute for conventional medical diagnosis and treatment. Techniques commonly employed in the application of acupuncture:
- Acupuncture needling – treatment will consist of the insertion of sterile disposable needles at specific sites on the body. Stimulation of said needles may be by manipulation, electrical stimulation or the application of warming substances (moxa) on the needle itself.
- Auxiliary / Associated therapies – massage, assisted stretching, topical application of liniments.
There is no guarantee that acupuncture will help any condition. Certain medications and social habits may decrease the beneficial eï¬€ects of acupuncture. These include the use and abuse of alcohol, tobacco, steroids, painkillers, narcotics, stimulants, antidepressants, psychopharmaceuticals and illegal drugs.
I, , certify that I have read and understood the statements above. I also certify that I have informed my acupuncturist of all known physical, mental and medical conditions and medications, and I will keep her updated on any changes.
Payment and Refund Policy
Payments can be made by Visa, Master Card, American Express, Discover, check or cash. Make checks payable to Acupuncture Remedies, P.C.. Full payment is expected at the time the services are rendered. There are no refunds for unused package sessions. All sales are final.
Explanation of Insurance Coverage
Many insurance policies do cover acupuncture care but this oï¬€ice makes no representation that yours does. Insurance policies may vary greatly in terms of deductible and percentage of coverage for acupuncture care. Because of the variance from one insurance policy to another, we require that you, the patient, be personally responsible for the payment of your deductibles, as well as any unpaid balances in this oïffice. We will do our best to verify your insurance coverage, and will bill your insurance in a timely manner.
If you must cancel your appointment, please notify us as soon as possible. In order to uphold our high standard of care, we must adhere to a standard 24-hour cancellation policy. Please note that you will be charged the full amount for less than '24-hour cancellations' and/or 'no-shows.
One's insurance cannot or will not be charged in lieu of a missed appointment. Patient will assume full responsibility for the missed appointment or late cancellation.
I, , certify that I have read and understood the statements above and agree to abide by them.
Notice of Privacy Practices
This Notice together with the Practices Regarding Disclosure of Health Information, describe how health information about you may be used and disclosed. They also describe how you can gain access to your health information. Please review this information carefully.
Understanding Your Health Record
A record is made each time you visit the office for treatment. This record includes symptoms, clinician observations, diagnosis and treatment. The record may also contain other pertinent information provided by you or another of your health care practitioners with whom we may have spoken.
Your Health Information Rights
This office owns your health record, however, the content is always available to you for your review. You have the right to request a review of your file and to obtain copies of documents contained in your file. You also have the right to request that amendments be made to you record. In addition, you may request that the use of your information be restricted from certain uses and disclosures and to request a list of individuals of entities to whom your information has been disclosed. You may revoke any authorizations you have given regarding disclosure of your health information at any time. This revocation must be provided to this office in writing.
We are required to maintain the privacy of your health information and to provide you with a copy of the Notice of our privacy practices. We will follow the terms of this Notice and advise you if we are unable to comply with a request you may make regarding the use of your health information. We reserve the right to amend our privacypolicies and we use our best efforts to notify you of any such amendments. Other than for reasons stated in this notice, we will not use or disclose your health information without your consent.
I, , have received a copy of the Notice of Privacy Practices and a copy of the Practices Regarding Disclosure of Patient Health Information. I understand my health information will be used and disclosed consistent with these Notices.
Standards and Practices - Privacy of Patient Information
Iris Netzer, L.Ac. and her team at Acupuncture Remedies are committed to treating all patients with appropriate care and respect. Information that patients provide to use in connection with their treatment, Protected Health Information (PHI), is subjected to standards of security and confidentiality as defined under Federal Law, the Health Information Portability and Accountability Act (HIPAA). These Standards and Practices set forth the procedures in insure compliance with the requirements of HIPAA.
1. Written or electronic files containing PHI must be stored in secure facilities. Written files will be maintained in locked file cabinets and electronic files will be stored in secure databases only accessible through password- protected codes. Computer screens will be positioned so that they are not viewable by persons other than personnel authorized to access that information. All personnel shall use discretion when discussing PHI in conversations.
2. A Notice of Privacy Practices together with the statement of Practices Regarding Disclosure of PHI will be provided to all patients at the time of their initial visit. All patients will be requested to sign a statement acknowledging receipt of this information. The acknowledgement will be kept on file for seven years.
3. Patients will be requested to advise the office whether it may contact them by phone or in writing regarding their care. It is our practice to call to remind patients of their appointments and to send billing and related information to patients homes.
4. PHI may be routinely used for treatment, billing, payment and quality control purposes. PHI may also be used without the patients consent for the following purposes:
a. uses and disclosures required by law
b. uses and disclosures for public health activities
c. disclosures about victims of abuse, neglect or domestic violence
d. disclosures for judicial and administrative proceedings
e. disclosures for law enforcement purposes f. uses and disclosures about decedents
g. uses and disclosures for cadaver or organ donation purposes
h. uses and disclosures to avert a serious threat to health or safety
i. disclosures for workers compensation
j. disclosures to a State Licensing Board or other professional oversight entity
5. Patients have the right to request restrictions on the use of their PHI although, we are not always able to abide by such requests. All such requests must be submitted in writing on our Restriction Request Form. We will take all such requests under advisement and notify the patient in writing of our determination. A copy of the determination will be maintained in our files. If the request is granted then it will be observed, except in the event of an emergency or in the event we terminate the agreement.
6. State law pertaining to parent/guardian authorization will apply in the case of a minor. When state law is silent, we reserve the right to use our professional judgment.
7. Non-routine requests for PHI will be reviewed in the normal course and may require specific patient authorization.
8. Patients may request an account of all PHI disclosures made in the prior six years. Such an accounting will not include disclosures:
a. for treatment, payment and healthcare operations
b. to the patient
c. to persons involved in the patients care
d. for national security or intelligence purposes
e. to correctional institutions of law enforcement agencies
f. disclosures made prior to the enactment of HIPAA
In some instances PHI may be used once it has been stripped of all elements of personally identifying information. Identifiers that may be stripped include:
b. all address information
c. email addresses
d. dates (other than year)
e. Social Security number
f. medical record numbers
g. health plan beneficiary numbers
h. account numbers
i. certificate numbers
j. license numbers
k. vehicle identification numbers
l. facial photographs
m. telephone numbers
n. device identifiers
p. ip addresses
q. biometric identifiers
r. zip code, if the geographic unit includes less than 20,000 persons
s. any other unique data which when used alone or in combination with other information might identify the individual who is the subject of the information
9. We are required to act on written requests for onsite review of PHI within thirty days of our receipt of the request. If copies are requested we may charge a reasonable copying fee. Patients do not have the right to access:
a. psychotherapy notes
b. information relating to criminal, civil or administrative procedures
c. PHI lawfully prohibited from release because it is subject to or exempted from Clinical Laboratory Improvements Amendments (CLIC)
d. information created by someone other than us given to use under a promise not to release
10. Patients have a right to request amendments to their PHI. Requests to amend must be made in writing, clearly stating the requested amendment and the reason for the request. We will provide a written response within 60 days. If un-amended information had previously been provided to third parties, we will undertake to advise any such person of the amendment. If the request is denied we will provide a written statement setting forth the basis for the denial.
11. Amendment Rights do not apply in the following circumstances:
a. the information is not part of the patient file
b. the information is accurate and complete
c. the information was not created by us
12. We shall designate a person who shall be responsible for developing and implementing out HIPAA policies and procedures. This person shall also be responsible for training all staff in these policies and procedures. All employees will be required to sign an Employee Agreement Form acknowledging that they have been trained and they understand their obligations. Employee infractions of HIPAA will result in discipline and may result in termination of employment. Similarly, any third party vendor who has access to PHI will be required to
acknowledge that they are HIPAA compliant in all services provided to our business.
13. We shall not adversely treat any patient who exercises his/her rights under HIPAA. The staff is expressly prohibited from intimidating, threatening, coercing, discriminating, or retaliating against any patient who exercises their HIPAA rights.
14. Any patient wishing to appeal a determination or to file a complaint regarding HIPAA should contact the Secretary of DHHS within 180 days of the alleged violation. All personnel shall fully cooperate with any resulting investigation. Complaints are to be filed with:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, SW Washington DC, 20201
Practices Regarding Disclosure of Patient Health Information
Your health information will be routinely used for treatment, payment and quality monitoring. Your consent is not required in these circumstances.
Treatment – Information obtained by us will be entered into your treatment record and used in the course of your treatment. Your health information may be shared with other health practitioners as we, in the exercise of our professional judgment, deem appropriate. Information regarding our assessment of your health and information regarding consultations may also be retained in your file.
Payment – Your record will be used to receive payment for services. A bill or other payment information may be mailed to your home or to a third party provider. That information will likely contain diagnostic determination, practitioner impressions and treatment procedures.
Quality Monitoring – We will use your health information to assess the care you have received and to compare outcomes. This information may also be used in conjunction with various scientific studies regarding your specific condition or Oriental Medicine itself.
The following disclosures are required by law and do not require your consent:
Food and Drug Administration (FDA) – We are required to disclose health information to the FDA related to any adverse effects of food, supplements, products, and product defects for surveillance to enable produce recalls, repairs or replacements.
Workers Compensation – We will release health information to the extent required under the workers compensation law.
Public Health – We are required to disclose health information to public health entities or legal authorities responsible for tracking birth and morbidity, communicable disease, injury or disability and matters relating to organ/cadaver donations.
Law Enforcement – We are required to provide your health information to law enforcement and professional oversight personnel under state and federal law. Similarly, we will disclose such information in the event we believe there is a risk of harm to yourself or others.
We also consider the following uses as routine use and disclosure. If you do not want your health information used in the following circumstances, please advise us in writing.
Business Associates – Professionals and others whose services we require in the normal course of our business. Examples include our accountant, lawyer and pharmacy. We require these individuals to follow the same procedures and standards as our staff.
Communication with family – We may contact a family member or some other person designated by you to assist them in enhancing your well-being.
Marketing and Fundraising – We may periodically send information to you regarding treatment alternatives and other health related benefits we believe may be useful to you. We may also request your charitable support on behalf of alternative medicine research projects or other medically related chartable events. This contact will not disclose information regarding your specific medical condition.