New Year Form Updates

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  • Financial Policy

  • We are dedicated to providing you with high quality healthcare. By signing this form, you acknowledge and intend to adhere to the financial policies set by our practice.

    Retaining Credit Cards on File Our office requires retention of an active credit or debit card on file via Credit Card Authorization form. We may use this card on file to bill any balances indicated as patient responsibility by your insurance or to reconcile any balances beyond 30 days. Health Savings and Flexible Spending cards are acceptable forms of payment; however, we will require an additional card on file in case the available funds on those cards have been exhausted. All credit card information is encrypted and stored securely and is not shared with any third party. If you elect not to keep a credit card on file with our office, you must pay for your services in full, prior to the services being rendered, regardless of if you are using private insurance to process your claim. There are no exceptions. Any patient credits that are a result of a claims processing will be applied to your account to use towards future balances (copays, coinsurance, services and/or products) or can be refunded to you upon request.

    Initial Evaluations and Re-evaluations For acupuncture, we administer a 30-minute initial evaluation for all patients. This service is usually performed via telehealth communication in our Frederick location, and in-office in our Boonsboro location. The self-pay fee for this service is $95.00. If you are using your insurance to process your claims, we will bill the service to your insurance company. If your insurance denies the charge, you will be financially responsible for the service in full. Your policy may also have additional copay for evaluation services. About once per month, your provider will also bill your insurance for a re-evaluation in addition to your acupuncture. This re-evaluation charge is the provider billing for the extra time spent evaluating your case. It may not necessarily mean that anything will be different with the acupuncture portion of your treatment. Our providers usually spend time on your case before and after the appointment which could mean thoroughly documenting their treatment notes, researching and evaluating your case, and/or discussing methods with other providers. The extra charge aside from acupuncture is for that time spent. Re-evaluations are a standard our office has set and occur across all patients and cases. If your insurance company denies any of the charges, you will be financially responsible for the services in full.

    Self-Pay Payment is due in full at the time of your appointment unless you have elected to pre-pay for services. We accept cash, check and credit card payments. There will be a $30 fee assessed to your account for a returned check.

    Private Insurance Our office(s) can bill your insurance company for acupuncture services. We do not bill insurance for massage but can provide you with a Superbill to submit for reimbursement. Beyond the practice of medicine, all healthcare providers are faced with the task of working with many different insurance companies who help coordinate your care and meet your medical financial responsibilities. By signing this form, you acknowledge your financial responsibility, including your responsibility to be aware of what your insurance does and does not pay for, as well as any patient responsibility amounts. Your insurance policy is a contract between you/your employer and the insurance company – our office is not party to that contract. Please read your Evidence of Coverage booklet that you received from your insurance company as to what types of services are not covered under your policy or contact your insurance company directly if you have specific questions about your coverage. After each appointment, we will bill your claim to your insurance for you and your insurance company will return an Explanation of Benefits (EOB) to us within 2-6 weeks. The EOB will contain details of how they processed your claim; dictating patient responsibility amounts and also any payment amount to our office. We currently accept and process for participating Aetna, Blue Cross Blue Shield, and United Healthcare plans that cover acupuncture. We will also process to insurance when Medicare is primary and one of the aforenamed insurance providers is secondary with acupuncture coverage. If you change insurance companies or employers, or your policy is updated or changed, you agree to provide our office with the current information immediately.

    Copays and Co-Insurance All copays and coinsurance are due at the time of service. Your policy may have additional copay for evaluation services.

    Deductible Your deductible is the amount your insurance company requires you to pay out of pocket before your insurance company will pay for your claims. If your policy is determined to have a deductible that applies to acupuncture, you will be charged the estimated deductible costs at the time of the appointment. Any differences determined after our receipt of the EOB from your insurance company, will be reflected on your account. Any additional balances owed will be due at your next appointment or during end of the month reconciliation – whichever comes first. Any balances beyond 30 days will be charged to your credit card on file. Any credits will be reflected on your account to use towards future purchases (copays, coinsurance, services and/or products).

    Denials If your insurance company denies services, we will do our best to appeal the claims on your behalf – we want to help! However, this is not a guarantee the denial will be overturned, and the claims will be paid. Although it is rare, sometimes your final insurance coverage determined during claims processing can differ from the information relayed originally. Not all diagnoses codes may be covered under your plan. Please be aware that some and perhaps all of the services provided may be considered non-covered or denied under your plan based on the limitations in your policy. Any non-covered or denied services will become your full financial responsibility. Any unpaid balances on your account after 30 days, will be charged to your credit card on file.

    Opting Out of Insurance If benefits are determined through your policy but you do not wish to process through your insurance, you have the option to sign an insurance waiver provided by our office and pay the self-pay rate for services instead.

    Worker’s Compensation and Motor Vehicle Accidents/Personal Injury We do not process to Worker’s Comp, Auto Accident or Personal Injury claims. In a case where a third party may be liable for payment of your bills, you are responsible for your charges and we require payment in full at the time of service. We can provide you with a Superbill receipt to submit for reimbursement upon request. We will not sign a Doctor’s Lien with your attorney. We are not legally permitted to bill your private insurance for these services unless subrogation has been identified in writing between your private insurance and your worker’s comp/personal injury insurance companies.

    Office Records A $40 fee will be assessed for a compilation of your medical records.

    Herb Return Policy Herbs returned within 2 months (60 days) from the date of purchase and unopened are eligible for a full refund.

    Cancellation Fee An appointment reserves time with a practitioner. To ensure that the maximum number of patients can receive care when needed, we require notification of any appointment changes 24 hours in advance of your appointment. A $75 fee will be assessed for any missed appointments or cancellations with less than 24-hour notice. Any cancelled/missed appointments are best to reschedule within the week to maximize your benefit of care and follow the treatment plan your practitioner has outlined for you. In the event of severe weather or medical emergency, exceptions to this policy are made. Electronic Appointment Reminders via text and email are sent as a courtesy and inability to receive one is not an excuse to miss an appointment. Ultimately, it is the responsibility of the patient to keep track of their appointments. Disputing cancellation fees or non-adherence to office policies could result in scheduling privileges being revoked.

    By signing this form, I have read, understand and agree to the Financial Policy of Holistic Health Associates described in this document. I have had an opportunity to ask questions and am fully aware of what I am signing. I intend this form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment or until a new form is signed and retained on file by this practice.

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  • Notice of Privacy Practices

    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.


  • OUR PLEDGE REGARDING HEALTH INFORMATION

    We care about our patient’s privacy and are committed to protecting the confidentiality of your medical information at this practice. We create a record of care about the services you receive here. We need this record to provide you with quality care and to comply with certain legal requirements. Current federal legislation requires that we issue this official Notice of our Privacy Practices. You have the right to the confidentiality of your protected health information (PHI) and we respect our legal obligation to keep health information that identifies you private. This practice (all medical professionals, all employees, staff and other personnel, subsidiaries and business associates (e.g. system software company)) are required to abide by the terms of the Notice Of Privacy Practices currently in effect, and to provide notice of its legal duties and privacy practices with respect to protected health information. We reserve the right to change this Notice at any time as allowed by law. If we change the Notice, the new Privacy Practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, the new Notice will be available upon request, in our office(s) and on our website. This Notice describes how we protect your health information and what rights you have regarding it.

    TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

    The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are (if applicable): allergies you may have to certain materials, herbs or supplements, setting up an appointment for you, calling to remind you of an appointment, prescribing herbal supplements, developing treatment plans, or referring you to another doctor, practitioner or clinic for services. Examples of how we use or disclose your health information for payment purposes are: so that the treatment and services you receive from us may be billed and payment may be collected from you; an insurance company or a third party or inquiring about your health care plan(s). “Health care operations” mean those administrative and managerial functions that we must do to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and storage of our records 

    APPOINTMENT REMINDERS, TREATMENT ALTERNATIVES AND HEALTH RELATED BENEFITS AND SERVICES

    We will send electronic appointment reminders as a courtesy to you via text and/or email unless you opt out of that courtesy. We may also contact you about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also leave voicemail messages, emails or text messages about your care unless indicated otherwise.

    INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE. When appropriately indicated, we may share Health Information with a person who is involved in your medical care or payment for your care, such as your family member or close friend. Proper authorization for release of information to persons other than the patient or getting copies of your health information from another professional that you may have seen before us will be given by written consent from the patient.

    RESEARCH  

    Under certain circumstances, we may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. In this situation, your name will not be used without permission, only the results of the treatment.

    OTHER USES OR DISCLOSURES THAT CAN BE MADE WITHOUT CONSENT OR AUTHORIZATION

    In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply; some may never come up at our office at all. Such uses or disclosures are:

    • when a state or federal law mandates that certain health information be reported for a specific purpose;
    • for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
    • disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
    • uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid if applicable; or for investigation of possible violations of health care laws;
    • disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
    • disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
    • disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
    • uses or disclosures for health-related research;
    • uses and disclosures to prevent a serious threat to health or safety;
    • uses or disclosures for specialized government functions, such as for the protection of the president or high-ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
    • disclosures of de-identified information;
    • disclosures relating to subrogation for worker’s compensation or personal injury programs;
      disclosures of a “limited data set” for research, public health, or health care operations;
    • incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
    • disclosures to business associates (Ex: software company) who perform health care operations for us and who commit to respect the privacy of your health information


    YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION 

    The law gives you many rights regarding your health information. You are welcome to request, in writing; a restriction; amendment or adjustment to the use or disclosure of your information. All written requests should be addressed to the Privacy Officer at the address listed at the beginning of this Notice. You have the right to:

    • request restrictions to our uses and disclosures for purposes of treatment, payment or health care operations. We are not required to agree to your request, and we may decline if we believe it would affect your health care.
    • request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full
    • communicate with you in a confidential way, such as phoning at work rather than home, by mailing health information to a different address, or via email to your personal email address. We will agree to all reasonable requests.
    • ask to see or obtain photocopies of your health information. You will be able to electronically review your information within 5 business days of your written request, once received and/or receive a hard copy of your health information within 15 business days of your written request, once received.
    • ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from the date the written request was received.
    • a list of all disclosures that we have made within the last six years (or any shorter period).
    • additional paper copies of this Notice of Privacy Practices upon request.

    COMPLAINTS 

    If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, please send a written complaint to the Privacy Officer at the address shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.

  • HIPAA Notice of Privacy Practices Acknowledgement

  • By signing this form below, I acknowledge I have been presented with the Notice of Privacy Practices explaining my rights under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regarding my individually identifiable protected health information (PHI) and have reviewed it carefully. I acknowledge that I have received a copy of HIPAA Notice of Privacy Practices and I consent to the use and disclosure of my PHI for purposes of treatment, payment or other health care operations. Other uses of my PHI will require an authorization from me for the specific intention of disclosure.
  • Thank you for your continued confidence in our practice and for supporting our requirements.

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Informed Consent for Care

Legal Name*
Date of Birth*
Is the patient being treated under the age of 18 (Minor)?*
Address*
By signing below, I hereby request and consent to the performance of acupuncture, massage therapy, and/or nutrition/health counseling treatments, injections, and other procedures within the scope of the practice of these respective forms of care on me (or on the patient named below, for whom I am legally responsible) by a licensed practitioner in the practice listed above. I understand that acupuncturists and massage therapists are not primary care providers and that regular primary care by a licensed physician is an important choice that is strongly recommended. I understand that services offered in the practice listed above are not a substitute for medical care. I understand that the practitioners who administer services within the practice listed above are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat physical or mental illness(es).

I understand that acupuncture is performed by the insertion of single use, sterile needles through the skin, at certain points on or near the surface of the body, with or without electrical stimulation and/or Nerve Reboot, in an attempt to treat bodily dysfunction or diseases, to modify or prevent pain perception, regulate and balance Qi (energy), improve organ function and overall health, and to normalize the body’s physiological functions. I understand that methods of treatment related to acupuncture may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, injections, and nutritional counseling. I understand that while needle insertion is a large part of the acupuncture treatment, it does not encompass the entire treatment during the appointment. I understand that the appointment time is in sixty-minute increments, however, my time in the treatment room may not reach a full sixty minutes. Needle insertion can be in the range of 25-45 minutes and my sixty-minute appointment time also includes the provider’s documentation of the treatment, which may occur after my appointment time. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may be 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.

Acupuncture typically involves safe methods of treatment; however, certain adverse side effects may result. These rare and unusual side effects could include but are not limited to, minor bruising or bleeding, soreness, numbness or tingling near the needling sites that may last a few days, dizziness, fainting, infection, spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax). Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. 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. I understand that if am pregnant, I am not eligible to receive QiGong Massage Therapy (QMT) services by this office and it is not recommended that I seek these services elsewhere. I understand that if I have had a recent surgical procedure, I must receive prior approval by a physician in writing and disclose this information to the treating practitioner before receiving massage treatment to protect my health and safety. I understand that there are risks involved with any medical procedure or service. I agree not to hold HHA liable for anything related or resulting from care received by any of our licensed and trained providers, and agree to engage in the services provided at Holistic Health Associates at my own risk. I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment. I understand that results are not guaranteed and that I am free to stop the treatment at any time. I understand that while this document describes the major risks of treatment, albeit rare, there are other side effects that may occur. I understand the clinical and administrative staff may review and discuss my patient records and lab reports within the practice, but all my records will be kept confidential and will not be released without my written consent. I affirm that I have notified my therapist of all known medical conditions in writing (medication and supplements, surgeries, and injuries) to identify contraindications for massage and acupuncture. I do agree to inform the practitioner of any changes in my health and medical condition(s) and I understand that there shall be no liability on that of the practice if I forget to do so or omit and information on my Intake Form. I understand that by signing this release, I hereby waive and release this practice listed above and its employees from all liability, past, present, and future relating to the services rendered.

I understand that all services rendered at Holistic Health Associates are entirely therapeutic and non-sexual in nature. I understand that Acupuncture, Massage and Reiki therapies are provided for stress reduction, relaxation, relief from muscular tension, and/or improvement of circulation and energy flow. I understand if unethical and inappropriate conversation, behaviors and/or actions are observed before/after/during any service or session rendered in this practice, the service will end immediately, my account will be flagged, and I will no longer be permitted to schedule future services.

I understand that I must be able to independently journey to my designated treatment room, undress to my comfort level, and transfer on and off the treatment table safely without assistance from practitioner or other staff unless discussed prior to my scheduled treatment. I understand that if more assistance is needed, I am required to bring a caregiver to assist me in these tasks.

I understand that any child/minor (under the age of 18) must obtain and provide prior approval in writing. I understand that any child/minor (under the age of 18) must also have a parent or legal guardian present during the service rendered for its entirety.

I understand that if my practitioner must cancel my scheduled service for any reason, I will be offered the option to reschedule.

Holistic Health Associates engages in electronic communication services. This includes video and audio telehealth appointments using a compliant platform, text message and email communication with staff through our private system, and automated appointment reminders. Our practice will use all reasonable means to protect the security and confidentiality of information sent and received. However, because of the risks outlined below inherent to all electronic communications, the security and confidentiality of electronic communications cannot be guaranteed. Electronic Appointment Reminders via text and email are sent as a courtesy and inability to receive one is not an excuse to miss an appointment. Ultimately, it is the responsibility of the patient to keep track of their appointments.
  • Use of electronic communications to discuss sensitive information can increase the risk of inadvertent disclosure of such information to 3rd parties.
  • Despite reasonable efforts to protect the privacy and security of electronic communications, it may not be possible to completely secure electronic information.
  • Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.
  • Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the participants.

By signing this document, I understand and accept the risks associated with the use of electronic communications as outlined above and consent to the use of these means to communicate with this practice and its employees.

I understand that even if I have received one or more doses of the Pfizer, Moderna, or Johnson & Johnson COVID-19 vaccines, there is still potential risk to contract or transmit bacteria/viruses to others while in close contact for an extended period of time, directly or indirectly. I understand that because therapies and services rendered by Holistic Health Associates involve maintained touch and/or close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. I understand that I should speak with our office regarding any illness symptoms I am experiencing so that HHA may guide me to the best course of action that aligns with HHA’s current COVID policies. I understand that if I am experiencing symptoms, my appointment may need to be rescheduled. I understand that this practice and all employees take safety measures seriously for both staff and patients alike, however, there is no guarantee to remove all risk of exposure to COVID-19 or any other communicable disease, bacteria or virus. I understand that education regarding COVID-19 is still formulating and therefore, our practice’s policies around COVID-19 are subject to change. I agree to adhere to all COVID-19 policies made known to me, set by this practice.

By voluntarily signing below, I show that I have carefully read, or have had read to me, all the above information and have been told about the risks and benefits of acupuncture, massage therapy, and other procedures and therapies. I have had an opportunity to ask questions and am fully aware of what I am signing. 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 or until a new form is signed and retained on file by this practice.
Signature of Patient, Legal Representative, or Parent/Guardian*
Date*