Informed Consent Hipaa Agreement Form
ADVERTISEMENT
1INFORMED
C ONSENT
T O
O RIENTAL
HIPAA
A ND
P RIVACY
P RACTIES
MEDICINE
H EATH
C ARE
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
disclose
you
health
information
without
your
there
are
some
risks
with
treatment.
I
understand
that
authorization.
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,
information.
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
Signature
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
713.942.7110
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