B I L L I N G P O L I C Y
Payment received at time of service / No Insurance
We are happy to provide the service of insurance billing to our patients at Zara Clinic. If you are unsure of your coverage for our services, we encourage you to call the number on your card to double check your benefits. Although we have contacted your insurance company, what they have quoted us is not a guarantee of payment, and as the patient you will be responsible for paying for any treatments your insurance does not cover. Please let us know if you have questions.
I authorize Zara Clinic to bill my insurance for services rendered. I understand that I am responsible for payment if my insurance denies the claim. I understand that benefits quoted are not a guarantee of payment by the insurance company. I understand that while Zara Clinic will do its best to let me know when authorizations are needed or my benefits have exhausted, it is my responsibility to keep track of my benefits. I understand that I must pay any co-pay required by my insurance at the time of service. I understand that I will be billed, and am responsible for, and must pay any co-insurance or deductible payments required by my insurance company.
Per our late cancelation policy there is a $25 late cancelation fee when you cancel or reschedule your appointment within 24 hours of your appointment. However we understand things come up so the first late cancelation fee is waived. Any late cancelations after you will be charged $25 per late cancellation. Thank you for your understanding.
Patient or Parent/Guardian Signature
I understand that some services may not be considered eligible benefits (e.g., services and/or supplies may be determined to not be medically necessary, non-covered or investigational) by my health insurance provider. I understand that my health insurance coverage has certain restrictions and limitations, such as authorization requirements and non-covered services. Examples of these non-covered items include, but are not limited to, report writing, conferences and/or meetings and supplies. I agree to be financially responsible for any and all related charges if they are not covered by my health insurance.
Patient or Parent/Guardian Signature
I N F O R M E D C O N S E N T
This form is required for treatment, please read it over carefully.
Naturopathic and Acupuncture: All therapeutic services performed by the Naturopathic Physicians at Zara Clinic are aimed to prevent and treat pain, disease, or other dysfunctions. Adverse side effects may result. These include, but are not limited to local bruising, minor bleeding, fainting, dizziness, temporary pain or discomfort, and temporary aggravation or symptoms existing prior to receiving treatments. Adverse side effects may result from taking nutritional supplements. These include, but are not limited to changes in bowel habits, temporary abdominal pain or discomfort, and the possible temporary aggravation of existing symptoms. If you experience any problems associated with supplements, you should stop taking them and contact your doctor. Some herbs and supplements are inappropriate for pregnancy. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tiu-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. 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. You, the patient, are responsible for notifying a clinical staff member if you are pregnant or become pregnant.
Massage Therapy: All massage therapy services performed by Massage Therapists at Zara Clinic are aimed at stress reduction, pain reduction, relief from muscle tension, or increasing circulation. Zara Clinic's Massage Therapists cannot and will not diagnose illness or disease, does not prescribe medical treatment or medications, and will not perform spinal manipulations as part of massage therapy. Massage therapy is not a substitution for medical care and it is recommended that you work with your primary caregiver for any condition you may have.
Esthetician: All voluntarily elected esthetician services conducted by Estheticians at Zara Clinic are aimed at treating specific problems in which the nature and purpose of each treatment, as well as the risks and hazards, is explained to me at the time of service.
Other Services, including Infrared Sauna: All other services, including the Infrared Sauna, tub, and light therapy, are voluntarily elected services provided by staff at Zara Clinic and are aimed at alleviating a myriad of issues. Due to the risks and hazards of some procedures based on your health questionnaire, services may be withheld. By receiving other services, including the infrared sauna, you acknowledge and voluntarily assume the risk of injury, accident or death. It is recommended that you receive permission from your doctor before undergoing Infrared Sauna treatment. Patients that are pregnant; currently experiencing fever, infection, or injury; recently been diagnosed with high blood pressure, heart attack, or other cardiovascular problems; have a history of dizziness, fainting spells, heath sensitivity, narcolepsy or seizures, or bleeding disorders it is not recommended that you use the infrared sauna and that you contact your physician to acquire a release form in order to utilize the Infrared Sauna.
I do not expect the staff at Zara Clinic to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the 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 results are not guaranteed.
I understand the clinical and administrative staff at Zara Clinic may review my patient records and lab reports, but all my records will be kept confidential according to Zara Clinic's HIPAA Policy.
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 the procedures I am receiving, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treament(s) for my present condition and for any future condition(s) for which I seek treatment.
N O T I C E O F P R I V A C Y P R A C T I C E S
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.
We are required by law to protect the privacy of your health information and to notify you of any breaches of your unsecured health information. We are also required by law to give you a copy of and follow the terms of the Notice, which sets forth our legal duties and privacy practices with regard to your health information.
Use and Disclosure of Your Health Information for Treatment, Payment and Operations: We may use and disclose your health information to give you care and to coordinate and management your treatment or other services. For example, we may disclose your health information to other health care providers who are not employed by Zara Clinic who is seeing you in his or her office. We may use and disclose your health information to bill and collect payment from you or your health plan for services received. For example, we may give information about your visit to your health plan so your health plan will pay us or reimburse you for the treatment. We may use and disclose your health information for our operations. For example, our staff may use your information to assess the care and outcomes in your case and others like it.
We may disclose to a family member, close personal friend, or other person you identify certain health information that is needed for that person's involvement in your care or payment for your care. We will disclose you health information when required to do so by federal, state or local law. We may disclose your health information to "business associates" which we contract to perform services on our behalf. We may disclose your health information for public health activities, such as the Public Health Authority and Food and Drug Administration. As allowed or required by law, we may disclose health information about an individual we reasonably believe to be the victim of abuse, neglect, or domestic violence to a government authority authorized to receive such reports. We may disclose your health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure. We may disclose your health information in response to a court or administrative order, subpoena, discovery request or other lawful process, as allowed or required by law. We may disclose your health information if asked to do so by a law enforcement official. We may disclose your health information to a medical examiner or coroner as necessary or required to identify a deceased person or determine the cause of death. We also may disclose your health information to funeral directors, organ donation, and tissue donation organizations so their can perform their duties. We may use and disclose your health information when we reasonably believe it necessary to prevent a serious or imminent threat to the health and safety of you, the public, or another person.
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
You have the right to inspect and obtain copies of health information that we may use to make decisions about your care. We may deny your request in certain limited circumstances. To inspect or obtain a copy of your health information, you must submit your request in writing to Zara Clinic. You may be charged a reasonable fee for the costs of copying, mailing, or other supplies related to your request.
If you feel that health information we have about you is incorrect or incomplete, then you have the right to request an amendment for as long as we keep this information. We may deny your request in certain situations. To request an amendment, you must submit your request in writing to Zara Clinic.
You have the right to request an accounting of certain disclosures of your health information made by us. To request this list or accounting, you must submit your request in writing to Zara Clinic.
You have the right to request that we communicate with you about health matters in a certain way or at a certain location. To request confidential communications regarding billing or health information, submit your request in writing to Zara Clinic. We are not required to agree to all requests, however if we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
You have a right to receive a written copy of this Notice. Copies are available at the front desk at any Zara Clinic.
We reserve the right to change this notice at any time.
If you believe that your privacy rights have been violated, you may submit a complaint to Zara Clinic by mail to: Zara Clinic, 5512 NE 109th Ct., Vancouver, WA 98662.
I consent to allow Zara Clinic the right to leave a message on my home answering machine, communicate with me by email, and communicate with me by text.
I understand and agree that Zara Clinic will not be held liable or in violation of this Notice for communications and interactions via social media outlets and is not responsible for any comments or posts that I may contribute to these sources.
I understand that if I, the patient, refuse to sign this consent form, Zara Clinic may refuse to provide certain services to me. I understand that if I, the patient, refuse to sign this consent form, my health care information cannot be given to insurance companies, and consequently, I, the patient will be responsible for the entire bill and will be billed accordingly.
ZCF-104 New Patient Intake Form (07-15) – Zara Clinic