INTAKE FORM ANDRE YERSHOV, L.Ac.
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PATIENT ADVISORY TO CONSULT A PHYSICIAN
To comply with Article 160, Section 8211.1(b) of NYS Education law, we advise you to consult a physician regarding the conditions for which such patient seeks acupuncture treatment
I have read and agree to the above *
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INFORMED COSENT TO ACUPUNCTURE TREATMENT
I consent to acupuncture treatments and other procedures associated with Traditional Oriental Medicine by the Licensed Acupuncturist named below. I have discussed the nature and purpose of my treatment with this person.
I understand that methods of treatment may include but are not limited to acupuncture, moxabustion, cupping, guasha, electrical stimulation and Tui Na (Chinese Massage).
I have been informed that acupuncture is a safe method of treatment, but that it may have side effects, including bruising, numbness or tingling near to needling sites that may last a few days and dizziness or fainting. Bruising is a common side effect of cupping or guasha. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although this clinic uses sterile, disposable needles and maintains a clean and safe environment. Burns and/or scarring are potential risks of moxabustion. I understand that while this document describes the major risks of treatment, other side effects may occur.
The herbs and nutritional supplements (which are from plant, animal and mineral sources), which may be recommended are traditionally considered safe, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, diarrhea, rashes, hives and tingling of the tongue. I will notify my practitioner of any unanticipated or unpleasant effects associated with the consumption of herbs.
I will notify my practitioner if I become pregnant.
I do not expect my practitioner to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on my practitioner to exercise judgment during the course of treatment which the practitioner thinks at the time, based upon the facts known to him, is in my best interests.
By voluntarily signing below, I show that I have read, or have had read to me, this consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intended 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 have read and agreed to the above *
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FINANCIAL AGREEMENT HEALTH INSURANCE
FINANCIAL AGREEMENT HEALTH INSURANCE

Explanation of Insurance Coverage:
Many insurance policies do cover acupuncture care but this office makes no representation that yours does. Insurance policies may vary greatly in terms of deductible and percentage of coverage for acupuncture care. Because of the variance from one insurance policy to another, we require that you, the patient, be personally responsible for the payment of your deductibles, as well as any unpaid balances in this office. We will do our best to verify your insurance coverage, and will bill your insurance in a timely manner.

Payment Agreement:
We require that you pay your co-pay that is required by your insurance provider towards today's charges and on each visit. Your full portion of the bill is expected to be when payment is received from your insurance carrier. Any unpaid balances will be considered past due 30 days following insurance reimbursement. Past due balances may have an interest charge of 1.5 % applied per month.

Assignment of benefits:
Attached is an "Assignment of Benefits" from which we would like you to agree. This form directs your insurance company to send payments directly to the office. If your insurance carrier sends payments to you for the services incurred in the office, you agree to send or bring those payments to this office upon receipt.

Release of Information
If your insurance company requires medical reports or records to document your treatment or progress, your agreeing below authorizes this office to release the medical information necessary to process your claim.

Voluntary Termination of Care
If you suspend or terminate your care at any time, your portion of all charges for professional services is immediately due and payable to this office. All services rendered by this office are charged directly to you, and you, ultimately will be personally responsible for payment regardless of your insurance coverage.

I have read and agree to the above *
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Insurance Company (if not applicable, print "none") *
Policy number (if not applicable, print "none") *
Member ID (if not applicable, print "none") *
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AUTHORIZATION AND INSTRUCTION FOR DIRECT PAYMENT TO DOCTOR
I hereby the above named insurance company to pay by check made out to and mailed directly to:

Andrey Yershov, L.Ac.
303 Fifth Ave, Suite 1501
NY, NY, 10016

For professional medical expense benefits allowable, and otherwise payable to me under my current insurance policy or by a 3rd party payor who would otherwise pay me directly, as payment toward the total charges for professional services rendered.

THIS IS AA DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY AND CLAIM.

This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional fees for non-covered services and/or fees, over and above the insurance payment or as required by the insurance policy.
I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney for the purpose of securing payment under this policy or insurance.
I have read above and agree *
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