New Patient Acupuncture Form:
New Patient Massage Form:
New Patients: click on the above icon to download your form. Please fill out and bring this form with you to your first visit, thank you!
- Adult new patient- 90 minutes
- Adult return visit- 60 minutes
- Prenatal new patient- 60 minute
- Prenatal return visit- 45 minutes
- Pediatric new patient- 30 minutes
- Pediatric return patient- 15 minutes
Please wear loose comfortable clothing. You may be asked to partially or fully disrobe (you will be appropriately draped) in order to access certain areas on the body that are necessary for the treatment of your condition.
STELLAR ACUPUNCTURE’S CANCELLATION POLICY
Stellar Acupuncture has a 24-hour cancellation policy. Cancellations made the day before, within the 24-hour window will incur a 50% late cancellation fee unless the appointment time is able to be filled by someone else. Same day cancellations will incur a 100% charge, unless the appointment is able to be filled by someone else. Failure to show up for your appointment will result in a 100% charge for your missed appointment.
Stellar Acupuncture is a small, appointment only business that relies on advanced bookings. When you schedule an appointment, you are reserving that time, which prevents other people from scheduling. We thank you for your understanding.
Your Health Information Rights (HIPAA)
You have the right to request restrictions on certain uses and disclosures of your health
information. If services are paid in full by cash you may restrict that information to any insurer for purposes other than for treatment.You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.
You have a right to request that we amend your protected health information. Please be advised, however, that we may not be required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial. You have a right to receive an accounting of disclosures of your protected health information made by Stellar Acupuncture.
You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.
Please note that this oﬃce submits insurance claims via electronic media and fax machine. If you are not comfortable with this, please notify us and we will use alternate methods.
Changes to this Notice of Privacy Practices
This oﬃce reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions eﬀective for all information that it maintains. Until such amendment is made, we are required by law to comply with this Notice.
FOR ADDITIONAL INFORMATION ABOUT YOUR PRIVACY, PLEASE VISIT: www.hcfa.gov/medicaid/hipaa
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW your MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Stellar Acupuncture is required, by law, to maintain the privacy and conﬁdentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.
Disclosure of your Health Care Information Communication
We may communicate the following information through one or more of these methods:
• In person
• By phone
• By Fax
• By US mail
• By Email
We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations.
“It is our policy to provide a substitute health care provider, authorized by Stellar Acupuncture to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary health care provider’s absence due to vacation, sickness, or other emergency situation.”
We may disclose your health information to your insurance provider for the purpose of payment or health care operations.
If payment is not made as arranged, our oﬃce may utilize an outside collection agency, credit reporting agency or other means of collecting outstanding debt. The designated collection agency or authority may review your ﬁle containing protected health care information. Workers’ Compensation
If applicable, we may disclose your health information as necessary to comply with state Workers’ Compensation Laws.
We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care, about your medical condition or in the event of an emergency or of your death.
As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. Judicial and Administrative Proceedings.
We may disclose your health information to a law enforcement oﬃcial for purposes such as identifying of locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena and other law enforcement purposes.
We may disclose your health information to coroners or medical examiners
Organ Donation & Research
Though highly unlikely or probable we must inform you that there may a need to release your health information to organizations involved in procuring, banking or transplanting organs and tissues, or to researchers conducting research that has been approved by an Institutional Review Board.
It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.
Specialized Government Agencies.
We may disclose your health information for military, national security, prisoner and government beneﬁts purposes.
Marketing & Other Communication
We may contact you for marketing purposes or fundraising purposes. We give reminders for appointment via email, text, or phone.