Informed Consent Hipaa Agreement Form


I   hereby   request   and   consent   to   the   performance   of  
A   record   is   made   each   time   you   visit   this   clinic.   Your  
acupuncture   and   other   Traditional   Chinese   Medicine  
symptoms,   the   acupuncture’s   judgment,   and   a   plan   of  
(TCM)  treatments  on  me  (or  on  the  patient  named  below,  
treatment   are   recorded.   This   record   serves   as   a   basis   for  
for   whom   I   am   legally   responsible)   by   the   licensed  
planning   your   care   and   treatment   at   future   visits.   Your  
acupuncturists   w ho   n ow   o r   i n   t he   f uture   t reat   m e   w hile   o n  
health   r ecord   i s   t he   p hysical   p roperty   o f   t his   c linic,   b ut   t he  
staff   w ith   E lement   5   O M.    
content   is   about   you,   and   therefore   belongs   to   you.   You  
have   the   right   to   review   or   obtain   a   paper   copy   of   your  
I  understand  that  the  scope  of  the  practice  under  Element  
health   r ecord.   Y ou   h ave   t he   r ight   t o   r equest   r estrictions   o n  
5   OM   includes   but   is   not   limited   to:   acupuncture,   herbal  
certain   uses   and   disclosures   of   your   information.     By  
therapy   and   other   oriental   medical   procedures   including  
signing   this   consent   form   you   agree   that   you   may   be  
diagnostic   techniques   such   as   questioning,   pulse  
contacted  by  staff  members  in  regards  to  appointments  or  
evaluation,   palpation   on   a   variety   of   areas   of   my   body,  
information   related   to   treatments.   If   this   contact   is  
observation,   range   of   motion,   muscle,   and   orthopedic  
unavailable   by   phone,   the   staff   member   may   leave   a  
testing;   modes   of   manuals   or   physical   therapy   such   as  
message   with   an   answering   machine   or   anyone   who  
massage,   manipulation   of   joints   and/or   viscera,   heat  
answers   t he   p hone.  
and/or   cold   therapy   and   electrical   and/or   magnetic  
stimulation;   the   prescription   of   herbal   and   homeopathic  
This   clinic   is   required   to   maintain   the   privacy   of   your  
medicines   as   well   as   dietary   supplements   and   dietary  
health   information   with   this   notice   of   our   privacy  
recommendations,   exercise,   discussion   and   advice  
practices.   We   are   required   to   follow   the   terms   of   this  
regarding   thoughts,   feelings,   sensations,   emotions   and  
notice   and   to   notify   you   if   we   are   unable   to   grant   your  
attitudes,   a nd   h ealthy   l ife   s tyle   c ounseling.  
request   to   disclose   or   restrict   disclosure   of   our   health  
information   to   others.   Other   than   for   the   reasons  
I   understand   and   am   informed   that,   as   in   the   practice   of  
described   in   this   notice,   this   clinic   agrees   not   to   use   or  
allopathic   medicine,   in   the   practice   of   Oriental   Medicine  
there   are   some   risks   with   treatment.   I   understand   that  
although   the   risk   of   avert   side   effects   are   extremely  
minimal,  they  are  possible.  This  could  include,  but  are  not  
By   signing   this   consent   form   I   acknowledge   that   I   have  
limited   too:   bruising,   bleeding,   skin   irritation,   pain   in   the  
read,  or  it  has  been  read  to  me,  and  I  fully  understand  the  
treated   area,   muscle   weakness   and   soreness,   brief  
Privacy   Practices   regarding   disclosure   and   patient   health  
generalized   fatigue   or   nausea,   sensations   of   heat   or   cold,  
tingling   or   numbness,   brief   lightheadedness   or   fainting,  
broken   needles   and   risks   of   infection   or   pneumothorax,  
and   t he   p ossible   a ggravation   o f   s ymptoms   e xisting   p rior   t o  
acupuncture   treatment   or   creation   of   new   symptoms.   I  
understand   that   no   guarantees   concerning   its   use   and  
effects   are   given   to   me   and   that   I   am   free   to   stop  
acupuncture   t reatment   a t   a ny   t ime.    
Printed   N ame  
By   signing   this   consent   form   I   acknowledge   that   I   have  
read   t his   i nformed   c onsent   f orm,   o r   i t   h as   b een   r ead   t o   m e,  
and   I   fully   understand   the   nature,   purpose   and   risks   of  
acupuncture   and   other   oriental   medical   procedures.     I   do  
Signature   o f   P atient’s   R epresentative  
not   expect   the   acupuncturist   to   be   able   to   anticipate   and  
explain   all   risks   and   complications   associated   with  
treatment   at   Element   5   OM.     I   wish   to   rely   on   my  
acupuncturist   and   their   judgment   in   my   best   interest,  
Printed   N ame   o f   P atient’s   R epresentative  
based   on   the   facts   I   have   given   them,   during   the   entire  
course   of   my   treatment.   I   have   had   an   opportunity   to   ask  
questions   a bout   t his   f orm’s   c ontent,   a nd   b y   s igning   b elow   I  
agree  to  the  named  procedures.  I  intend  this  consent  form  
Relationship   o r   A uthority   o f   P atient’s   R epresentative  
to   c over   t he   e ntire   c ourse   o f   t reatment   f or   m y   p resent   a nd  
any   future   conditions   for   which   I   seek   treatment   at  
Element   5   O M.  
Date   S igned  
Element   5   O M  
2610   P ersa   S te.   4 ,   H ouston,   T X   7 7098  


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