CLIENT CONTACT and GENERAL INFORMATION
EMERGENCY CONTACT INFORMATION:
In case of emergency notify:
If you were referred to us, who can we thank?
Please select the payment coverage you expect to use (Self-Pay, Health Insurance, Auto Insurance PIP, L & I Insurance) and fill in the required information.
Financial Agreement and Policies
RESPONSIBILITY OF PAYMENT
I understand that I am ultimately responsible for payment for all Lake Washington Wellness services and products provided to the Client listed on this form. I understand if I am a parent or guardian registering a minor I am ultimately responsible for the payment of the charges incurred at Lake Washington Wellness.
ON FILE CREDIT CARD
I understand that Lake Washington Wellness requires that I have an active Credit Card on file for the purposes of holding appointments and for the payment of services, products, insurance co-pays, coinsurance, unreimbursed insurance claims, missed appointments and late cancel fees.
MISSED APPOINTMENTS, LATE CANCELLATION & LATE ARRIVAL POLICY
- I understand that if I miss an appointment I am responsible for a $110.00 NO SHOW Fee which I authorize be charged to my on-file credit card.
- I understand if I arrive 15 minutes late or later for an appointment, my appointment will be rescheduled due to insufficient time to treat and I am responsible for a $65.00 LATE CANCEL FEE which I authorize be charged to my on-file credit card.
- I understand if I do not cancel my appointment 24-hours prior to my appointment date and time, regardless of the reason, I am responsible for a $65.00 LATE CANCEL FEE which I authorize be charged to my on-file credit card.
APPROVAL OF OUTSTANDING BALANCES PAID USING ON-FILE CREDIT CARD
I understand that if I have an outstanding balance with Lake Washington Wellness, that Lake Washington Wellness will email statements to the email I have provided (if no email is provided, I understand the statement will be sent to the mailing address on file) and that any outstanding balance on the statement will be charged to my on-file credit card 15 days after the email (or mailing) sent date unless other arrangements have been made. I understand I am responsible for paying off my balance regardless of discrepancies and or disputes. I further understand if Lake Washington Wellness is unable to charge the on-file credit card, that my balance is due within 5 days. I understand unless payment arrangements have been made, delinquent accounts (45 days past initial billing date) will be referred to an independent collection agency or small claims court, in which case I will assume the full responsibility for collection costs, including any attorney and/or court fee.
USE OF INSURANCE FOR PARTIAL OR FULL PAYMENT
I understand that if I use insurance for partial or full payment of services or products, that I am providing authorization for my insurance benefits to be paid directly to Lake Washington Wellness.
I understand that my insurance is an agreement between the insurance company and myself. I understand that Lake Washington Wellness will assist me in billing my insurance carrier. However, I am fully responsible for all payments that are due, this includes any copays, coinsurance, and payment in full for any claims that are unreimbursed due to deductibles and claim denial by the provided insurance carrier. I understand it is my responsibility to be aware of my insurance coverage and benefit information in or out of network. (To verify benefits and obtain any information regarding your insurance plan and coverage, contact your benefit plan carrier.)
I understand if I do not provide my insurance information and prescription prior to my appointment, Lake Washington Wellness cannot bill my insurance and I will be required to pay for the service at the time of service.
I understand that if I have not provided a prescription prior to my appointment thatI must pay for service at the time of serviceand I have a right to a refund provided I obtain a backdated prescription and submit it to Lake Washington Wellness within five calendar days of my visit.
As a Client of or guardian of a Client of Lake Washington Wellness I acknowledge that I am solely responsible for payment of all charges incurred while under treatment. I understand any unpaid balance not paid by the insurance company becomes my responsibility regardless of the in or out of network coverage.
I understand authorization for treatment may be required by my health insurance benefit plan. If I receive treatment without an authorization, or an authorization request is denied, I accept all financial responsibility for treatment provided. I understand maintenance of care may be considered medically necessary by my physician but is excluded from coverage on my insurance benefit plan. I understand if I am denied authorization, due to time and labor costs, Lake Washington Wellness does not assist in appeals and the appeal process is my responsibility.
I understand that Lake Washington Wellness does not accept third party claim information for motor vehicle accident claims. I understand that Lake Washington Wellness will not wait for settlement/payment on a third-party car accident claim. I understand Lake Washington Wellness will work with my lawyer/legal team in any aspects except financial arrangements and settlement. I understand if I provide third party information, I will be responsible for all costs during and after my treatment. I understand that any unpaid visits will be reported to a collection agency after 90 days if not paid regardless of a settlement pending.
OUT OF NETWORK INSURANCE BILLING
I understand that if I am choosing to have Lake Washington Wellness bill my insurance out of network that I am responsible for checking my coverage and benefit information. I understand that I as the patient I take full responsibility for any cost after the insurance processes or does not process the claim and pays or does not pay for services and products provided. I understand that all above financial agreement policies apply to me regardless of billing out of network.
CONSENT FOR RELEASE AND EXCHANGE OF INFORMATION
I give permission to Lake Washington Wellness to release information that is necessary for Lake Washington Wellness to receive payment for the services and products provided. I understand that this information may be conveyed verbally or in writing, and that said documentations or information may be transmitted in person or by the means of communication systems, such as fax machines, telephones, non- secure email, or through the postal system in a sealed envelope.
Client or Parent/Legal Guardian Signature:
Massage Health Information
If you have been provided a prescription for the Massage Therapy,
please list the prescribing Physician/Chiropractor:
1. Areas of primary complaint:
*2. Have you received a massage before?
If yes, when was the last time?
*3. Have you received massage before related to your primary complaint?
*4. What is your preferred massage pressure?
Light Light-Medium Medium Medium-Deep Deep
5. If your visit is injury or health issue related, please explain how your symptoms started:
6. Date your symptoms/injury started (if applicable):
(If symptoms came on gradually please choose a date that symptoms prompted you to seek treatment.)
7. Prior to this onset, were you free of these symptoms?
*8. Have you had any previous or current treatment for this problem?
If yes, what?
9. If you answered yes, to question 8, do you feel your previous treatment made it:
Better Worse Same
10a. What eases the pain?
10b. What aggravates the pain?
*11. Have you had an MRI related to this problem?
*12. Do you have any numbness/tingling?
If yes, where?
13. On a Scale of 0-10, 1 being NO PAIN and 10 being WORST PAIN, what is the Level of Pain Intensity?
14. Select the Type of Pain
15. Pain Frequency: As a percent of time during the day select the Frequency of Pain
16. Please complete these sentences with a numerical %:
of the time, I am unable to Stand.
of the time, I am unable to Walk.
of the time, I am unable to Climb Stairs.
of the time, I am unable to Lift.
of the time, I am unable to Work.
of the time, I am unable to Wash, Dress, etc.
of the time, I am unable to Drive.
of the time, I am unable to Sit.
of the time, I am unable to Sleep.
If you are able to do everything listed above (fully functional), are you experiencing any pain related to these?
17. Please use the diagram below and use your mouse to circle or mark the areas of pain and discomfort.
18. Please list all Medications/Supplements you are taking and why:
19. Please List Any Allergies (fragrance, lotion, food, etc.):
20. Are you Pregnant?
If yes, due date:
*21. Are you experiencing headaches?
Average # of Headaches per week:
Type of Headache:
22. Please list any surgeries, accidents or traumas:
PLEASE CHECK ANY OF THE CONDITIONS BELOW THAT APPLY:
Abrupt Weight Gain or Loss
Excessive Hair Loss
Blood in Stool
Heartburn or Acid Reflux
Loose Stools and/or Diarrhea
Undigested Food in Stool
MUCSCLE and JOINT PAIN
Arthritis, Tendonitis, Bursitis
Low Back Pain
Sore or Weak Knees
Irregular Menstrual Cycle
Gallstones (history or current)
High pitched ringing in ears
Rash, Warts, Hives
Unable to adapt to stress
EMOTIONS AND SLEEP
Anger, Frustration, Irritable
Anxiety and/or Panic Attacks
Mental Heaviness & Fogginess
Over thinking, Worry
Snoring and/or Sleep Apnea
Cold Hands and Feet
High Blood Pressure
Irregular Heart Beat
Low Blood Pressure
Ringing in Ears
Shortness of Breath
HABITS AND USE
How often do you exercies per week?
How many alchoholic drinks do you have per day?
How many Cigarettes do you have per day?
Do you use recreational drugs?
How many cups of coffee do you drink each day?
Additional info you would like your therapist to know about any of the boxes checked:
HEALTH RISK, INFORMATION DISCLOUSRE AND INFORMED CONSENT FOR IN-PERSON SERVICES
HEALTH RISKS OF IN-PERSON SERVICES
You understand that the wellness work (Massage, Acupuncture or other services) provided at Lake Washington Wellness involves close physical proximity over an extended period in a closed space, which can elevate the risk of disease transmission, including COVID-19.
You understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). You further understand that COVID-19 is extremely contagious and may be contracted from various sources. You understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.
You understand that Lake Washington Wellness has implemented reasonable preventative measures and sanitation protocols intended to reduce the risk of disease transmission, including COVID-19.
You hereby acknowledge and assume the risk of becoming infected with COVID-19 or other public health risks through the treatments you receive at Lake Washington Wellness and you give your express permission to Lake Washington Wellness and the Licensed Staff at Lake Washington Wellness to proceed with providing care.
YOUR RESPONSIBILITY TO LIMIT YOUR EXPOSURE TO HEALTH RISKS
To obtain our health care services, you agree to take certain precautions which will help keep everyone safer from exposure to viruses and serious illness. If you do not follow the following safety standards, Lake Washington Wellness reserves the right to deny services.
1. You agree to cancel your in-person appointment if you have had symptoms of illness that are associated with contagious diseases such as the coronavirusand the fluin the past 72 hours.If you cancel for this reason, wewill not charge you our normal cancellation fee.
2. You agree to take your temperature before coming to each appointment. If your temperature is 100 Fahrenheit or moreyou agree to cancel the appointment. If you cancel for this reason, wewill not charge you our normal cancellation fee.
3. You agree to arrive no earlier than 5 minutes before your appointment.
4. You agree to wash your hands when you enter the building and before entering the clinic.
5. You agree to follow the safe distancing precautions we have set up in the waiting room and hallways.You will keep a distance of 6 feet (except while receiving treatment) and there will be no unnecessary physical contact (e.g. no shaking hands) with us or other visitors in our office.
6. You agree to wear a mask in all areas of the office. If you do not have a mask we will provide one.
7. If someone with whom you have contact tests positive for coronavirus or other highly infectious and life threating viruses, you agree to immediately let us know.
RIGHT TO REFUSE PROVIDING SERVICE
You understand that Lake Washington Wellness is committed to keeping you and all our Clients safe from the spread of disease. If you arrive for an appointment and the Staff at Lake Washington Wellness believes that you are exhibiting symptoms that could indicate the possibility of being infected with a transmissible disease or believe you have been exposed to a transmissible disease, like the coronavirus, you will be required to and you agree to leave the office immediately. Your appointment will reschedule as appropriate.
YOUR RESPONSIBILITY TO INFORM CLINIC AND THERAPIST OF PAIN, DISCOMFORT or CHANGE OF HEALTH
You understand that to provide the most effective treatment, you need to inform the Therapist of any pain or discomfort you are experiencing during this session. This includes informing the Therapist of any discomfort related to techniques or pressure being used. You also understand that if there is a change in your health between sessions, you will advise Lake Washington Wellness and the Therapist prior to your treatment.
CONSENT FOR RELEASE AND EXCHANGE OF INFORMATION
You understand that if Lake Washington Wellness is required by law to notify local health departments that you have been to our office you agree to allow Lake Washington Wellness to provide the information necessary to comply with the law. You give permission to Lake Washington Wellness to request or release information about your health care and any documentation of information concerning your carefor the purpose of case collaboration with the goal of advancing your health or insurance reimbursement.
You understand that you are the decision maker for your health or the decision maker for minors health. This process is often referred to as “informed consent” and involves your understanding and agreement regarding the risks associated with the provision of health care including those associated with a pandemic like COVID-19.
You knowingly and willingly consent to the wellness treatment at Lake Washington Wellness with the full understanding and disclosure of the risks associated with receiving care during the COVID-19 pandemic.
You have read or have had this document read to you and you accept that it is not possible to consider every possible complication to care. You also agree that you have had the opportunity to contact Lake Washington Wellness with questions about this Informed Consent form and preventative measures and sanitation protocols.
AGREEMENT TO RECEIVE CARE
By signing below, you understand and agree to the contents of this Informed Consent document along with the current or future recommendation to receive care as is deemed appropriate for your circumstance or the circumstance of a Minor for whom you are the Parent or Guardian. You agree that this Informed Consent covers the entire course of care from all providers in at Lake Washington Wellness, Redmond, WA for your present condition and for any future condition(s) for which you seek care at Lake Washington Wellness, Redmond, WA.
This agreement is made in addition to any other general informed consent or business agreement that has been made between you and Lake Washington Wellness.
Client or Parent/Legal Guardian Signature:
LAKE WASHINGTON WELLNESS NOTICE OF PRIVACY
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.
You have the right to:
- Get an electronic or paper copy of your 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 have 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
You have 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 EXPLAINED
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 will 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 have 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 will 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 at our offices by phone or in-person.
- 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/
- We will not retaliate against you for filing a complaint.
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.
- We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you asks another doctor about your overall health condition.
RUN OUR ORGANIZATION
- We can use and share your health information to run and improve our practice. 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 services 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 must 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
- 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 are 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.
Client or Parent/Legal Guardian Signature Below: