Consent to treat with Acupuncture, Telemedicine & Intuitive Wellness Services
SAHARA SUN MS, EAMP, LAc
Sahara Sun provides acupuncture and telehealth services under her scope of practice as a licensed East Asian Medical Practitioner nationally and in the state of Hawaii (NCCAOM 136978, HI 1005). Therefore, within the State of Hawaii, Sahara Sun can provide holistic counseling, wellness therapy, nutritional counseling, and herbal or nutritional supplements, as clinically appropriate, in person and by distance formats such as telephone or other teleconferencing options.
Sahara also travels outside of the state of Hawaii to provide intuitive wellness consultations. Sahara will NOT use needles outside of the state of Hawaii but will provide moxa and acupressure. If you work with Sahara in person, outside the state of Hawaii, you will be receiving intuitive counseling support from a Shamanic 5 Element Taoist approach and Jung psychology. She will also offer shamanic spiritual healing, other modalities of energy medicine and acupressure.
EAST ASIAN INFORMED CONSENT TO TREAT
I understand and I am informed that, as is with all Healthcare treatments, results are not guaranteed and there is no promise to cure. I further understand and I am informed that, as is with all Healthcare treatments, in the practice of East Asian Medicine there are some risks to treatment. I do not expect the practitioner to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioner to exercise judgment during the course of the procedure which they feel at the time, based upon the facts then known, is in my best interests.
I hereby request and consent to the performance of East Asian Medical treatments and / or other holistic procedures, including but not limited to Interview (history taking), Physical examination, dietary advice and therapeutic nutrition (such as the therapeutic use of foods, diet plans, nutritional supplements, intravenous and intramuscular injections), Acupuncture (insertion of specialized disposable stainless steel sterilized needles through the skin into underlying tissues at specific points on the body surface), Botanical medicines and nutraceuticals [also referred to as supplements] (such as the prescribing of various therapeutic substances including plant, mineral and animal materials. Substances may be given in the forms of teas, pills, creams, powders, tinctures-which may contain alcohol, suppositories, topical creams or other forms.), Homeopathic remedies (highly diluted substances), Various modes of physical therapy and any supportive therapies on me (or on the patient named below, for whom I am legally responsible) by the East Asian Medical Practitioner indicated below and/or other licensed practitioners and support staff who now or in the future treat me while employed by, working or associated with or serving as back-up for the practitioner named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.
I understand and I am informed that in the practice of East Asian Medicine as with all healthcare treatments there are risks and benefits with evaluation, diagnosis and treatment including, but not limited to the following:
Potential Risks: pain, discomfort numbness or tingling near the needling sites that may last a few days, dizziness or fainting, minor bruising from acupuncture as well as unusual risks such as spontaneous miscarriage, nerve damage, pneumothorax; allergic reaction to prescribed herbs, supplements; an aggravation of pre-existing symptoms.
Potential Benefits: restoration of the body’s maximal functioning capacity, relief of pain and symptoms of the disease, assistance in injury and disease recovery and prevention of disease or its progression.
Notice to pregnant women: all female patients must alert the provider if they know or suspect that they are pregnant since some of the therapies could present a risk to the pregnancy.
I have had an opportunity to discuss with the East Asian Medical Practitioner named below and/or with other office or clinic personnel the nature and purpose of naturopathic care and procedures.
I further understand that there are treatment options available for my condition other than the scope of practice in Shamanic and East Asian procedures. I understand and have been informed that I am being instructed to a second opinion and secure other healthcare professionals with the concerns as to the nature of my symptoms and treatment options.
If it is deemed necessary for the prescriptions of herbal formulas, nutritional supplements, topical, hormone or lab testing, Sahara uses an online dispensary. You will get email notifications of these recommendations from the dispensary, not Sahara. It is the patient's responsibility to create an account to receive healthcare recommendations and access to order.
EMERGENCY CARE IS NOT PROVIDED
I also understand that Sahara does not treat Emergency or Crisis Care. I understand that it is my responsibility to have other healthcare providers in place to support the work I am doing with Sahara. If there is a medical emergency I understand that I am being instructed to contact my primary care doctor, psychotherapist or emergency 911.
Sahara will contact your emergency contact in the registration form if she feels you are in crisis and need further assistance or support.
Because of the realities of telehealth services, Sahara cannot be available for urgent situations; in the event of medical, psychological, or other emergencies, please call 911 or seek whatever emergency services or crisis centers are available in your local area.
Further, should referrals to other healthcare professionals become relevant, Sahara will make a reasonable effort to help you find such services or professionals in your area, but cannot provide referrals in all regions.
I am aware that Sahara will work with me during our scheduled appointment and will respond to email inquires at her earliest convenience.
I understand that all payment(s) for treatment(s) are final and no refunds will be issued. However, prorated fees for unused, prepaid treatments will be refunded if I wish to cancel the treatment.
Sahara is considered an Out-of-Network-Provider to insurance companies (NPI 1033407960). She does not take health insurance but can supply you with a superbill to submit to your insurance company. You are responsible for payment up front. She is not responsible for what insurance companies do not cover.
Once you schedule your appointment, you will receive an email confirmation with instructions to join Sahara on the phone or video communication.
NOTICE OF PRIVACY PRACTICES
This notice describes how health information about you, as a patient of this practice, may be used and disclosed and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information.
Use and disclosure of your health information in certain special circumstances
The following circumstances may require us to use or disclose your health information:
To public health authorities and health oversight agencies that are authorized by law to collect information.
Lawsuits and similar proceedings in response to a court or administrative order.
If required to do so by a law enforcement official.
When necessary to reduce or prevent a serious threat to your health and safety or the health and safety or another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.
If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
To federal officials for intelligence and national security activities authorized by law.
To correctional institutions or law enforcement officials, if you are an inmate or under the custody of a law enforcement official.
For Workers Compensation and similar programs.
Your rights regarding your health information:
You can request that our practice communicates with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.
You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Sahara Sun, EAMP, LAc at the address listed at the top of this form. Note: We must respond to this request within 30 days.
You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Sahara Sun. You must provide us with a reason that supports your request for amendment. Note: We must respond within 60 days. The Privacy Officer or the patient’s physician will usually do this. If the physician believes the information is complete and accurate, the physician can refuse to make any changes.
You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact the front desk receptionist.
If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, the complaint must be made in writing and submitted to Sahara Sun. You will not be penalized for filing a complaint.
Our practice will obtain your authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.
If you have any questions regarding this notice or our health information privacy policies, please contact firstname.lastname@example.org
By clicking ‘Terms of Agreement' in the form, you are acknowledging receipt and access to the Notice of Privacy Practices.
If you work with Sahara online, all aspects of Sahara Sun's Consent for Treatment form remain also applies for telehealth services, including policies related to missed sessions, fees, and all other areas and considerations.
Sahara Sun is not responsible for any problems with communications equipment, other devices, or access to phone or internet connection; full fee will be charged for the entire scheduled session time, even if you are unable to get through, lose connection, or experience any other interruptions of service due to access or technological issues at your end. Should any technological or other issues at Sahara's end result in significant communication problems or loss of session time greater than 5 minutes, Sahara will either pro-rate the charge for that session or will make up a commensurate amount of session time at another juncture, at her discretion.
You may elect to engage in telehealth services with Sahara Sun by telephone (voice only), Skype, or Zoom (preferred mode of communication).
Zoom is the only HIPPA compliant option for video conferencing at this time. So, please note that Skype may not be entirely secure methods of communication, and confidentiality cannot be guaranteed; therefore, use of these services is entirely at your discretion. Sahara has instilled extra security features to ensure your privacy. Therefore, Sahara assumes no responsibility for any resulting breaches of confidentiality.
I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content. By clicking ‘I agree’ below, I consent to the above-named procedures and terms of condition to treat. I intend for this agreement to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
As always, feel free to contact Sahara at email@example.com any time with concerns or questions.