NL OON Disclosure Form - Amazon S3 › storage.qisites.com › uploads › ...106 4th St. Hoboken NJ 07030 Nurturing Life Acupuncture & Wellness PA (201) 526‐4684 [email protected]

1064thSt.HobokenNJ07030

NurturingLifeAcupuncture&WellnessPAwww.nlacuwell.com

(201)526‐[email protected]

INSURANCE PARTICIPATION STATUS AND FEES DISCLOSURE FORM

Under the New Jersey “Out-of-network Consumer Protection, Transparency, Costs Containment and Accountability Act”, P.L.2018,c.32 (the “Act”), health care providers and health care facilities are required to disclose to “covered persons” (a person on whose behalf a carrier is obligated to pay health care expense benefits or provide health care services) the health benefits plans in which the health care provider participates as well as the health care facilities with which the health care provider is affiliated. Therefore, please be advised that Nurturing Life Acupuncture & Wellness PA (the “Practice”) is disclosing the following to the patient (or the patient’s parent or legal guardian as set forth at the end of this Disclosure Form) (the “Patient”): Facilities the Practice is Associated with and Address(es):

None

Licensed Assistant Healthcare Staff: The following licensed healthcare professionals may perform assistant services to the Patient based upon the Patient’s treatment plan and needs as determined by the Practice:

William R. Wright, Jr. M.S.Ac., Dipl.Ac., L.Ac. Tanvi Dodia M.S.O.M., Dipl.OM, L.Ac.

Health Benefits Plans The Practice Participates With:

None

If the Patient’s health benefits plan is not listed above, the Practice (and potentially the health care facilities listed above, if any) do not participate with the Patient’s health benefits plan. In order to proceed with any such services for which the Practice is out-of-network with the Patient’s health benefits plan, the Patient hereby acknowledges and agrees:

1) The Patient understands that the Practice (and all of its licensed health care professionals) that the Patient is seeking healthcare services from is out-of-network with and does not participate with the Patient’s health benefits plan;

2) The Patient understands that the amount or estimated amount the Practice will bill the Patient for the services is available upon request;

3) The Patient understands that the Patient may request from the Practice an estimated charge for the services proposed and the Current Procedural Terminology (CPT) codes associated with that service, and the Practice will disclose to the Patient, in writing, the amount or estimated amount that the health care professional will bill the Patient for the service, and the CPT codes associated with that service, absent unforeseen medical circumstances that may arise when the health care service is provided;

4) The Patient understands that the Patient will have a financial responsibility applicable to health care services provided by an out-of-network professional, in excess of the Patient’s in network copayment, deductible, or coinsurance, and that the Patient may be responsible for any costs in excess of those allowed by the Patient’s health benefits plan.

5) The Patient has been advised that the Patient should contact the Patient’s health benefits plan or administrator for further consultation on those costs. The Practice and Patient both acknowledge and agree that receipt or acknowledgement by Patient of these disclosures

shall not waive or otherwise affect any protection under existing statutes or regulations regarding in network health benefits plan coverage available to the Patient under the law.

The Practice further acknowledges and agrees that if, between the time these disclosures are made to the patient and the time the health care service takes place, the network status of any of the Practice changes as it relates to the Patient’s health benefits plan, the Practice shall notify the Patient promptly.

Acknowledgement of Receipt of Disclosure Form

I, the undersigned Patient (or the Patient’s parent or legal guardian), acknowledge receipt of this Disclosure Form from the Practice, have read it and understand the above provisions. I have discussed my option to obtain treatment with other health care providers or at alternative health care facilities that may participate with my health benefits plan and I waive the right to do so and wish to obtain my treatment at the Practice with full notice of the above disclosures and potential costs that going to an out-of-network provider such as the Practice.

By: _______________________________ Date: ________________

Print Name of Patient: _________________________

If signing on behalf of the Patient indicate whether a parent or legal guardian of the Patient:

Acupuncture?

William R. Wright, MSAc, LAc 106 4th StreetHoboken, NJ 07030(201) 526-4684

neck

106 4th St. Hoboken NJ 07030

Nurturing Life Acupuncture & Wellness PA www.nlacuwell.com

(201) 526-4684 [email protected]

INFORMED CONSENT AND PRIVACY POLICY I hereby request and consent to the performance of Chinese Medicine treatments including acupuncture and other procedures on me by _________________________, L.Ac., (hereinafter referred to as "my acupuncturist") or any other licensed acupuncturist practicing at Nurturing Life Acupuncture & Wellness PA. I understand that Chinese Medicine treatments may include, but are not limited to acupuncture (including electrical stimulation of needles), moxibustion, cupping, tui-na (Chinese massage) and other East Asian forms of massage, gua sha, traditional Chinese herbal medicine, qigong and lifestyle/dietary counseling. I understand that acupuncture is generally a very safe method of treatment with few, but some possible side effects including bruising, pain, numbness or tingling at the needle site that may last a few days, and dizziness or fainting. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile single-use disposable needles and maintains a clean and safe environment. Bruising is a common side effect of cupping and gua sha. Moxibustion and the use of heat therapies may in rare instances cause burning or scarring. Chinese herbs (which are from plant, animal, and mineral sources) that are recommended are traditionally considered safe when practiced by professional practitioners of Chinese Medicine, although some may be toxic in large doses. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I understand that some herbs are inappropriate during pregnancy or combined with other herbs or prescription medications. I will notify my acupuncturist if I become or suspect that I am pregnant. I will also inform my acupuncturist of any drugs (medicinal or recreational) and supplements that I take and any changes in those drugs or supplements. I will notify my acupuncturist if I have a history of fainting. I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications and I understand results cannot be guaranteed. I understand that Traditional Chinese Medicine's assessment of my condition is not the same as a conventional medical diagnosis. I understand that herbs may need to be prepared and the teas consumed according to instructions provide to me either orally or in written form. The herbal teas may have an unpleasant smell and taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant side effects associated with the consumption of herbs. I understand that __________________ or any other licensed acupuncturist providing treatment to me may review my patient records with other acupuncturists in the office as well as other staff in the office as needed for insurance filings, but that all of my records will be kept confidential and will not be released without my written consent. I also understand that my acupuncturist or office staff may from time to time send me information via mail or email including but not limited to receipts, newsletters, and office announcements, but that my name and contact information will never be released to any other business or organization (other than my insurance company if I am covered for acupuncture). I understand that I may receive a full printed copy of this consent and privacy policy if I request it.

CERTIFICATION

By voluntarily signing below, I certify that I have read, or someone has read to me, the above consent to treatment, I have been told about the benefits and risks of the above procedures, and I have had the opportunity to ask any questions that I had. I intend for 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. I also confirm that my acupuncturist has advised me of the importance of consulting a licensed physician regarding my condition, as required by New Jersey state laws. ________________________________________________________________________________________ Patient Name (Please Print) ________________________________________________________________________________________ Patient Signature (or patient representative) Date ________________________________________________________________________________________ Acupuncturist Signature Date




Health Insurance Portability and Accountability Act (HIPAA) Notice This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Each time you visit a health care provider, a record of your visit (containing your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatments) is made. This Information is often referred to as your health or medical records and serves as a:

• Basis of planning your care and treatment • Means of communication among the health professionals participating in your care • Legal document describing the care you received • Means by which you or a third-party payer can certify that the services billed were actually provided • A source of Information for public health officials • An outcomes tool with which we can improve the care we deliver

Understanding what is in your record and how your health information is used helps you to ensure its accuracy; make more informed decisions when authorizing disclosure to others; and better understand who, what, when, where, and why others may access your health information. Understanding Your Health Information Rights Although your health record is the physical property of the healthcare provider, the information belongs to you. You have the right to:

• Request a restriction on certain uses and disclosures of your information • Obtain a paper copy of the notice of Information practices upon request • Inspect and obtain a copy of your health record • Request to amend your health record • Obtain an accounting of disclosures of your health information • Request communications of your health Information by alternative means or at alternative locations • Revoke your authorization to use or disclose health Information except to the extent that action has already been taken.

We are required to:

• Maintain privacy of your health Information and abide by the terms of this notice • Provide you with a notice as to our legal duties & privacy practices with respect to your information. • Notify you if unable to fulfill a requested restriction on disclosure or amendment to record • Accommodate reasonable requests you may have to communicate health information by alternative means or locations.

We reserve the right to change our practices and to make the changes effective for all protected health information we maintain. If our information practices change, we will notify you the next time you come to our office for treatment. If you have questions and would like additional information, you may contact our clinic. If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer or with the Secretary of Health and Human Services. We will not retaliate if you file a complaint. I understand that Nurturing Life Acupuncture & Wellness PA will use and disclose health information about me in the course of providing care to me. I understand that my health information may include information both created and received by the clinic, may be in the form of written or electronic records or spoken words, and my include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information. By signing below, I agree that I have reviewed this privacy practice and agree to these conditions. I will be offered a copy of this form and may request a copy at any time. Printed Name: _____________________________________ Signature: _____________________________ Date: _______________ RELEASE OF INFORMATION In order to provide the best care possible, we may need to discuss your case with other health care professionals and health care facilities. I authorize Nurturing Life Acupuncture & Wellness PA to release my medical records to my physician and other health care professionals. I also authorize Nurturing Life Acupuncture & Wellness PA to request pertinent medical records from these professionals. Please list pertinent professionals and their contact information: Provider: ________________________________ Provider type: ____________________________ Phone: ____________________

Provider: ________________________________ Provider type: ____________________________ Phone: ____________________

Patient Name (printed): _______________________________ Signature: _____________________________ Date: _______________




ASSIGNMENTOF BENEFITS AND RIGHTS DIRECT PAYMENT TO DOCTOR

PRIVATE/GROUP ACCIDENT AND HEALTH INSURANCE I hereby instruct and direct my insurance company to pay the following provider direct payment for services rendered:

Nurturing Life Acupuncture & Wellness PA, William Wright, L.Ac. 106 4th Street, Hoboken, New Jersey 07030 If my policy provisions prohibit direct payment to my acupuncturist, I hereby request payment for services rendered per current policy provisions. Payment is for the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment towards charges for professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS UNDER THE POLICY. The payment will not exceed any indebtedness to the above mentioned assignee and I have agreed to pay, in current manner, any balance of said professional service charge over and above this insurance payment. A photocopy of this Assignment of Benefits and Rights shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.

Initial_______________ We are happy to be able to accept insurance payments for our services. For your convenience, we accept a payment of your coinsurance at the time of your appointment and then bill the insurance company for the remaining amount. Please be aware that most insurance companies send the insurance payment checks directly to you even though you have assigned the benefits to us. Even though the check is in your name, this is the insurance company's payment for the services that we provided and therefore, it is our property. If you receive a check directly from your insurance company, please bring the check along with any accompanying paperwork to us. DO NOT CASH THE CHECK. For your safety, you may endorse the check on the back with your signature followed by the statement "Payable to Nurturing Life Acupuncture & Wellness PA". If you receive a check that includes payment for other providers, you may bring us a copy of the check and the Explanation of Benefits that details the payment for our services along with your personal check for the amount payable to Nurturing Life Acupuncture & Wellness PA. Failure to provide us with the insurance payments made to you for services rendered by Nurturing Life Acupuncture & Wellness PA is theft in the state of New Jersey and if the amount is at least $200 but less than $500, it is punishable by up to 18 months in prison and a fine up to $10,000. If the amount is greater than $500 but less than $75,000, it is punishable by 3 to 5 years in prison and a fine up to $15,000 or double the amount of the outstanding payments. I, ___________________________________________, understand that if my insurance company sends a check to me, I am responsible for bringing that check and the accompanying statement to Nurturing Life Acupuncture & Wellness PA as payment for services rendered.

Initial_______________ We are happy to verify your insurance coverage for acupuncture prior to treatment and to bill your insurance company accordingly. We encourage you to read and understand your insurance plan as well. While we work hard to ensure that your insurance pays what your policy covers, there are situations where the insurance company will deny payment. In that event, you are responsible for paying the full cash rate for the session less any coinsurance payment that you have already made. I, __________________________________________, understand that in the event my insurance company denies payment for services I have received at Nurturing Life Acupuncture & Wellness PA, I am responsible for paying the cash rate for my sessions less any coinsurance I have already paid and that my credit card on file may be charged for that payment and I will be notified of the charge.

Initial_______________ ____________________________________________________________ Patient Name (Please Print) ____________________________________________________________ ________________________ Signature Date




APPOINTMENT CANCELLATION POLICY

“Life is what happens while you are busy making other plans.” John Lennon

We recognize that things come up and changing plans is unavoidable. If you need to cancel an appointment, doing so more than 24-hours in advance will allow us to offer our time and care to others in need. For cancellations within 24 hours of the appointed time, we reserve the right to apply cancellation fees as follows:

• Less than 24 hours, but more than 4 hours prior to the scheduled appointment: $50 • Less than 4 hours prior to the scheduled appointment: full price • No show: full price

For those times when being on time is just impossible, please note our late arrival policy:

• All treatment sessions begin at the appointed time and should end an hour later. • Patients arriving after the appointed time, but less than 15 minutes late, will be treated in a

shortened session to accommodate following appointments. • Patients arriving more than 15 minutes late may be treated in a shortened session at the

discretion of the practitioner. • Regardless of the length of a shortened session, the patient is responsible for the full price. • Arrivals more than 30 minutes late can unfortunately not be taken, and will be viewed as No

Shows per the cancellation policy above.

__________________________________________________ Name (Please print) By signing below, I acknowledge that I have read and agreed to the Appointment Cancellation Policy as stated above. ______________________________________________ ______________________ Signature Date

Documents

NL OON Disclosure Form - Amazon S3 › storage.qisites.com › uploads › ...106 4th St. Hoboken NJ 07030 Nurturing Life Acupuncture & Wellness PA (201) 526‐4684 [email protected]