Patient Form Packet - jacqui von voss | holistic health

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.
TYPES OF INFORMATION WE GATHER AND USE:
In administering your health care, we gather and maintain information that may include non-public personal
information. For example:
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You financial transactions with us (billing transactions).
Your medical history, treatment notes, all test results, and any letters, faxes, emails or
telephone conversations to or from other health care practitioners.
Information from health care providers, workman’s comp and your employer, and other
third party administrators (e.g. requests for medical records, claim payment information).
YOUR RIGHTS UNDER THE FEDERAL PRIVACY STANDARD:
Although your health record is the physical property of Jacqui von Voss Holistic Health, you have certain rights
with regard to the information contained therein. You have the right to:
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Request restrictions on the use and disclosure of your health information for treatment and payment.
You may ask us to communicate with you by alternative means, and, if the method is reasonable, we must
grant the request.
You have the right to receive and keep a copy of this notice of information practices. If you do request a
copy, the law requires us to ask you to acknowledge receipt of your copy.
You have the right to inspect and copy your health information upon request. We reserve the right to charge
a reasonable, cost-based fee for making copies.
You have the right to request a correction of your health information unless we did not create the record or
the information is accurate and complete.
You have the right to obtain an accounting of non-routine uses or disclosures.
You have the right to revoke authorization to use or disclose your health information at any time.
WITH THE REGULATORY CONSENT GRANTED BY THE HEALTH AND HUMAN SERVICES
DEPARTMENT WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION FOR TREATMENT,
PAYMENT AND OPERATIONS. FOR EXAMPLE:
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Jacqui von Voss Holistic Health can use your personal health information to diagnose, plan and implement
the best course of treatment for you.
Jacqui von Voss Holistic Health may use your health information to receive payment from a third party
payer such as Workers Compensation, if applicable and appropriate.
OUR RESPONSIBILITY UNDER THE FEDERAL PRIVACY STANDARD:
 Maintain the privacy of your health information, including implementing reasonable and appropriate
physical, administrative, and technical safeguards to protect the information.
 Provide you with this notice as to our legal duties and privacy practices with respect to individually
identifiable health information about you that we collect and maintain.
 Abide by the terms of this notice.
 Train any personnel concerning privacy and confidentiality.
 Implement a sanction policy to discipline those who breach privacy/confidentiality policies.
 Lessen the harm of any breach of privacy or confidentiality.
Receipt of Privacy Notice
Consent for Purposes of Treatment, Payment and Health Care Operation
I consent to the use or disclosure of my identifiable health information by Jacqui von Voss Holistic Health
for the purposes of diagnosis or providing treatment to, obtaining payment for my health care bills or to
conduct health care operations. I understand that diagnosis or treatment of me at Jacqui von Voss Holistic
Health may be conditioned upon my consent as evidenced by my signature on this document.
I understand I have the right to request a restriction as to how my identifiable health information is used
or disclosed to carry out treatment, payment or health care operations of the practice. Jacqui von Voss
Holistic Health is not required to agree to the restrictions that I may request. However, if Jacqui von Voss
Holistic Health agrees to a restriction that I request, the restriction is binding upon Jacqui von Voss Holistic
Health.
I have the right to revoke this consent, in writing, at any time except to the extent that Jacqui von Voss
Holistic Health has taken action in reliance on this consent.
My identifiable health information means health information, including my demographic information,
collected from me and created or received by my practitioner, another health care provider, or my
employer. This identifiable health information relates to my past, present or future physical or mental
health or condition and identifies me, or there is a reasonable basis to believe the information may
identify me.
I understand I have the right to review Jacqui von Voss Holistic Health’s Notice of Privacy Practices prior to
signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my
identifiable health information that will occur in my treatment, payment of my bills or in the performance
of health care operations of Jacqui von Voss Holistic Health. This Notice of Privacy Practices also describes
my rights and the duties of Jacqui von Voss Holistic Health with respect to my identifiable health
information.
Jacqui von Voss Holistic Health reserves the right to change information contained in the Notice of Privacy
Practices at any time. I may obtain a revised Notice of Privacy Practices by requesting the most current
notice during any office visit.
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Signature of Patient or Authorized Representative
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Date
Consent to Treatment Form
I hereby request and voluntarily consent to the performance of Craniosacral therapy, acupuncture and other Oriental
medicine procedures on myself-_____________(or on the behalf of ____________) by Jacqui von Voss Holistic
Health.
I understand that methods or treatments may include but are not limited to Craniosacral therapy, acupuncture,
moxibustion/heat therapy, cupping, acupressure, myofascial release, and nutritional counseling. I understand that
Acupuncture is the insertion of fine sterile needles, with or without the addition of stimulation, through the skin,
and/or the application of heat to improve blood circulation, organ function and improve health.
I have been informed that acupuncture is a generally safe method of treatment, but on rare occasions, certain side
effects may result including dizziness, fainting, minor bruising, minor bleeding, pain, numbness or tingling near the
needling sites that may last a few days. I also understand there is always a possibility of an unexpected
complication. I understand that no guarantee can be made concerning the results of treatment.
Are you currently pregnant?_________ If yes, I have been informed of the possible risks and contraindications of
treatment while pregnant.
I understand that the evaluation given to me is an energetic assessment of the functioning of the Acupuncture
Meridian network and organ systems, as well as the functioning of the Craniosacral and myofascial systems; it in no
way purports to be, or replaces allopathic (western) medical evaluation, diagnosis, or treatment. I understand that the
practitioner Jacqui von Voss is not a physician and does not diagnose or treat medical conditions. I have been
advised to consult a physician for any medical problems I may have and, in the event that I am receiving other
conventional medical treatment, I have been advised to inform my physician of the proposed complementary
therapies. In addition, I have been advised to consult a physician if any new symptoms should arise. If there is
worsening of my ailment or condition or it does not improve within the time estimated by the practitioner, I am
aware that I should consult a physician. I understand I am fully responsible for all decisions I make regarding
whether and when to seek medical treatment.
I understand that I may refuse or stop treatments at anytime. I have read, or have had read to me 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 any future condition(s) for which I seek treatment.
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Release of Information: I understand it may be necessary for my practitioner to contact another one of my
health care providers in order to coordinate medical treatment, to discuss an emergency situation and/or to
share appropriate medical information. My signature gives my practitioner permission to release my medical
records for the reasons listed above. ________ (initials)
Missed Appointment Policy: I agree to pay the full charge for any missed or forgotten appointments without 24hour notice of cancellation. ________ ( initials). I agree to pay all charges incurred for services rendered at
the time of visit ________ (initials)
Patient’s Printed Name
Date:
Patient’s Signature
Witnessed by:
For: __________________________ Signed by Representative/Guardian