Merriam Park Acupuncture Intake Forms

Our clinic is dedicated to providing service with respect and dignity. Protecting your privacy and healthcare information is of utmost important with respect to our relationship. We are required to tell you how we will be keeping your protected information confidential. This notice describes our office’s policy for how medical information is used and disclosed, how you can access your information and how your privacy is protected. Your signature is required on receipt of this information. This notice will remain in effect until it is replaced or amended by changes in law.

We may gather personal information and health information in several ways. Information we receive from you, information we receive from other healthcare providers, information we receive from third party payers.

Your health information may be used for the following purposes:

You should be aware that during the course of our relationship you will likely use and disclose health information about your treatment, payment, and healthcare operations. For the purpose of this notice, “health information” includes everything you disclose to us including your name, address, email address, and telephone number.

We may use your health information to provide, coordinate and manage healthcare treatment or services within this clinic. We may, with your written consent, disclose health information about you to other healthcare professionals who are involved in treating you.

We may use information to receive payment from you, an insurance company or third party for services we provide to you.

We may use health information for certain activities related to business function within this office.

We may use health information to contact you as an appointment reminder, to reschedule an appointment or to contact your regarding your treatment/condition.

With your written consent we may disclose your information, to your family members, personal friend, or any other friend which would directly relate to your health care or payment for such healthcare.

We may disclose or use minimally necessary and legally required health information about you for research purposes.

We may disclose or use minimally necessary health information for other special situations such as public health activities, for averting a serious thereat to health, or safety for workers’ compensation purposes.

We may disclose minimally necessary health information about you when required to do so by federal, state, or local law.

You may specifically authorize us to use protected health information for any purpose, or to disclose our health information about you, by submitting an authorization in writing. Such disclosers will be made to any personal representative you designation to share your personal protected health information.

This office will send you newsletters via email or use telephone calls for the purpose of communication or scheduling.

Patient rights:

Upon written request you have the right to access, review or receive copies of your health care records.

Upon written request you have the right to receive a list of items this office disclosed about your healthcare information.

You have the right to request that this office place additional restrictions on disclosure of your protected health information.

You have the right to request that we amend your protected health information . The request mush be in writing.

If you have questions or complaints or want more information call 651-207-3019. Complaints about your privacy rights or how your privacy is handled at the clinic can be directed to the privacy officer by calling this office or directing a letter to their attention. Dawn Pivec, 1523 Selby Ave., St. Paul, MN 55104

If you are not satisfied with how this office has handled your complaint you may submit a formal complaint to U.S. Department of Health and Human Services, 200 Independent Ave SW, Room 509 F, HHH Building, Washington, DC 20201.

I understand that all of these therapies may be utilized during my course of treatment and that some side effects may occur. I understand I may discontinue these treatments at any time. I will ask my acupuncturist for more detailed descriptions at any time.

Acupuncture is performed by insertion of pre-sterilized, disposable needles through the skin and application of heat or electric stimulation to the needle at certain points on the body. Side effects may include, but are not limited to: bruising, minor bleeding, dizziness, fainting, nausea, temporary aggravation of symptoms, muscle soreness. The most serious side effects, although rare are pneuma-thorax, nerve damage, or infection.

Cupping is a therapy that involves using glass cups applied to an area of the body and applied with a suction device or lighted flame to create suction and used for the therapeutic purpose of invigorating blood flow to an area of the body. Sometimes discoloration of the skin that looks like bruising can happen. Sometimes pain near the suction site can happen.

Chinese herbs may be recommended for internal or external use to balance the body and regulate the body’s physiological process. Herbal side effects allergic reactions, nausea, gas, stomachache, vomiting, headache, diarrhea, rash, hives and tingling of the tongue. Some possible side effects of applying topical creams, liniments, ointments and plasters are rashes, hives and tingling of the skin. Herbal medicine is inappropriate for pregnancy. All opened herbal formulas are non-refundable. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical 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 that, as with all healthcare approaches, results are not guaranteed, and there is no promise to cure.

I understand that, although Merriam Park Acupuncture is taking every step possible to prevent the spread of COVID-19, the only way to fully protect myself from getting the virus is to stay home. I have read the clinic’s COVID-19 procedures and will abide by them. I do not hold Merriam Park Acupuncture liable if I contact COVID-19.

I understand that I am ultimately responsible for any charges if my insurance does not cover my treatments. I will work with Merriam Park Acupuncture on a fair price after all attempts and appeals have been made to get coverage. I authorize my personal information for electronic submission to my insurance company (if applicable).

I understand that a 24 hour notice is required to reschedule or cancel appointment. I understand that I will be charged a $50 fee for no shows or late cancelation. I will not be charged for illness, emergency, or inclement weather.

I agree to get text and email reminders. I agree to receive updates via email about Merriam Park Acupuncture. I will call if I no longer want to receive these reminders.

Please fill this out to the best of your ability.

Please Note, Insurance will only cover the management of chronic pain. To check on coverage call the number on the back of your card for member services and answer the following questions. If this form is left blank, we will assume that you are paying our cash rate of $95 for the first session and $75 for the following sessions.