Eastern Medicine has been practiced for over five thousand years throughout the world and its effects have been approved for treating many conditions.

Consent for Eastern Medicine Treatment

I, the undersigned, realize that these techniques of acupuncture, which may be applied to me, including herbal remedies, needles with or without electric stimulation, moxibustion, acupressure and tai chi therapy, electrical devices, and cupping (phlebotomy) may be from Korea, China, Japan, or America.

1. Acupuncture or Electric Stimulation: A method of treatment using well-sterilized disposable needles to pierce the skin. There will be no risk factors or serious side effects.

2. Moxibustion, Heating or Cold Pack: Moxa wool is used to warm the Acupuncture points. When moxibustion is used, there is no chance of any burn.

3. Acupressure or Tai Chi Therapy: Acupressure is used with the following methods such as pressing acupuncture points with the fingers, elbows, or palms, and manipulation of the joints. This method works with four groups including the meridian group, the acupoint group, the muscle group, and the joint group. Tai Chi therapy is a modified exercise that is provided to the patient for certain disorders.

4. Herbal Remedies: Uses herbs to help with some internal disorders, cleansing, and improving general health conditioning remedies. There is no hazard to your health. The tea is provided in disposable packs using a well sterilized process to extract the herb. Also, the pills provided are well sterilized and safe, personally produced for certain disorders.

5. Cupping (Phlebotomy): Cupping techniques are used for certain problems such as sprains or strains. Phlebotomy, draws blood to be sent to a lab for analyzing certain diagnosis.

6. Insurance: This office will be happy to complete your insurance forms. However, each patient is responsible for payment of the fees to the clinic and any reimbursement by the insurance company will be strictly between the patient and their company.

I understand that I must be diligent and follow the instructions given by the doctor to protect myself and maximize treatment of my condition. The nature of the treatment has been explained to me and I fully understand that there is no stated or implied guarantee of success or effectiveness of a specific treatment, or series of treatments. Of course, every effort will be made to achieve success. I realize that I may withdraw from the treatment at any time. Therefore, I, the above patient, do hereby for myself, and my Doctors, waive, release, and forever discharge any and all rights and claims whatsoever, for any damages which I may have.

Date:___________________ Patient's Signature:______________________________________

Patient's Name:_______________________ Sex:____ Birth Date:________ Marital Status:_____

Address:___________________________________________________________________

Tel (Home): __________________________Tel (Office):______________________________

Occupation:____________________ Insurance: Yes [] No [] Referred by:________________

How did your pain begin? (Answer below)

Following an accident [ ] Following surgery [ ] Following an illness [ ]

Began without any relation to anything [ ] It is related to other circumstances [ ] (Explain)___________________________________________________________________

How long ago did the pain begin? ______________Where did it start?____________________

Where does it hurt now?_____________________ What type of work do you do?___________

Is your pain related to your job? Yes [ ] No [ ] (If the answer is yes, please explain)____________________________________________________________________

How many hours do you sleep a day?______ How many hours do you work a day?________

Have you ever had related present pain before? Yes [ ] No [ ]

Did you receive any other treatment from another doctor with the same symptoms? Yes [ ] No [ ] (If the answer is yes, please explain)__________________________________________

Do you take any kind of medication or drugs? Yes [ ] No [ ] (If the answer is yes, Please explain)_____________________________________________________________________

Are you allergic to any of the following: Foods [ ] Plants [ ] Medicine [ ] Other [ ]

If you are allergic to any of the above, please explain:_________________________________

Any other Disease? Yes [ ] No [ ] (If the answer is yes, please explain)____________________________________________________________________

Are you currently pregnant? Yes [] No [] If answer is yes, how many months?_________

I have been evaluated by an other physician for the condition being treated within six months before the acupuncture was performed. Yes [ ] No [ ]

I understand that the acupuncturist is required to refer me to an other physician if no substantial improvement occurs in the condition being treated after thirty (30) days or (20) treatments, whichever comes first. It is my responsibility and choice to follow this advice.

Signed:_____________________________________ Date:______________________

Note: This is a confidential record of your medical history and will be kept in this office. Information contained here will not be released to any person except when you have authorized us to do so.

PRIVACY POLICIES                                            Effective Date: April 14, 2003

THIS NOTICE DESCRIBES HOW HEALTHCARE INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

YOUR PRIVATE HEALTH INFORMATION (PHI)

Each time you have contact with a healthcare provider for delivery of healthcare, a record of your contact/visit is prepared. This record, maintained in written, oral or electronic format, contains presenting signs/symptoms, results of examination and tests, diagnosis, treatment and future care. Your medical record is the physical property of the CLINIC, but you have certain rights to restrict some of the uses or disclosures of the information in your medical record. The CLINIC, however, has the right to use and disclose the information contained in your medical record in the process of providing treatment, receiving payment and performing other regular healthcare operations such as:

Documenting and describing the care you received for legal purposes

Communicating with other healthcare providers who may be involved in your care

Educating health care professionals

Medical research

Providing information for government and public health entities responsible for improving public health and welfare

Evaluating and improving the care your receive and the outcomes achieved

Billing and verification of services provided to you

Conducting other routine healthcare operations such as quality improvement studies and assessing healthcare provider competence

Protecting your privacy and maintaining the security of your health information is an important responsibility of this CLINIC. This CLINIC is required by law to maintain privacy and confidentiality of your health information, provide you with this Notice of Privacy Practices, notify you of your rights to restrict use of this information, notify you if the CLINIC is unable to agree to a requested restriction, and allow you to review the Notice of Privacy Practices prior to granting consent and notifying you of changes/revisions to this Notice.

I understand that as part of my healthcare, OHTC Health Care System, PLLC originates and maintains health records

describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future

care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services

provided to me, to communicate with other healthcare providers and other routine healthcare operations such as

assessing quality and reviewing competence of healthcare professionals.

A. EXAMPLES OF DISCLOSURE OF YOUR PHI

Healthcare delivery and treatment:

information obtained from you by a physician, nurse, acupuncturist or other healthcare professional is documented in your record and used for the assessment, evaluation, diagnosis and treatment of your medical condition(s). This information may be provided to other healthcare professionals, such as other physicians, acupuncturists, specialists, physical therapists, hospital based providers and/or other healthcare

providers following your treatment by this CLINIC.

Billing and payment:

You PHI is utilized to justify the level of care delivered to you and the charges incurred for the services.

This information generally accompanies the bill and is sent to our payers and other third party administrators.

Other healthcare operations:

The CLINIC may disclose your PHI to other individuals and businesses in order for the CLINIC to perform its day-to-day operations. These other individuals and businesses include business associates such as vendors and/or contractors used for credentialing and peer review, patient satisfaction surveys, utilization review/utilization management, billing and claims management, medical research, disease management, and quality improvement initiatives, as well as management services organizations, laboratories, free standing diagnostic facilities and legal counsel. The CLINIC requires all its business associates to agree to appropriately protect the confidentiality of you PHI.

Reminders and Treatment:

The CLINIC may contact you to provide your with information that we feel is useful or helpful to you, based on your PHI. For example, the CLINIC may contact you (or instruct a specialist physician to whom you have been referred to contact you) to schedule an appointment or as an appointment reminder, to suggest alternative treatment, or to provide you with information on treatments you are already receiving.

Other Uses and Disclosures:

The CLINIC may also utilize or disclose your PHI in order to communicate with or notify family members, relatives and others responsible for your health, and funeral directors. In addition, the CLINIC may disclose your PHI though other communications and reports required to be made by healthcare professionals such as the public health department, law enforcement, the Food and Drug Administration, organ procurement organizations, correctional institutions, and workers compensation, where applicable. Other uses and disclosures of PHI not permitted or required by law will be made only with your written authorization. You may revoke your authorization at any time provided that the revocation is in writing, except to the extent that the CLINIC has already taken action in reliance on your prior authorization.

B. YOUR RIGHTS CONCERNING PHI

Except as otherwise provided by law, you have the right to:

C. receive a paper copy of this Notice of Privacy Practices if you have agreed to receive it electronically.

D. receive confidential communications of PHI if a request is submitted to the CLINIC in writing;

E. inspect and copy PHI or records about you in a designated record set as long as the PHI is maintained in the record set;

F. as the CLINIC to amend PHI or records about you in a designated record set as long as the PHI or record is maintained in the record set (the CLINIC is not required to change the information if it deems it to be accurate);

G. receive an accounting of disclosures of PHI (a list of the disclosures made by the CLINIC about you for reasons other than for treatment, payment or health care operations); and

H. request that the CLINIC restrict uses or disclosures of you PHI. Though the CLINIC is not required to agree to a restriction, to the extent that it does agree with your request, the CLINIC may not use or disclose the protected PHI in violation of the restriction unless the information is needed to provide emergency treatment, or is otherwise permitted or required by law.

The CLINIC is required by law to abide by the terms of this Notice of Privacy Practices, allow you to review this Notice prior to granting consent, and notify you of changes/revisions to this Notice. If you believe your privacy rights have been violated, you may submit a written complaint to the CLINIC or the Secretary of Health and Human Services describing in detail the manner in which you feel your privacy rights have been violated. The CLINIC will not retaliate against you in any way for filing a complaint with the CLINIC, or with the Secretary.

For further information regarding PHI, please contact the Privacy Officer listed on Patient's Consent Regarding Use and Disclosure of Health Information.

OHTC Health Care System, PLLC

This CLINIC's Notice of Privacy Practices provides specific information and complete description of how your personal health information may be used and disclosed. I have been provided a copy of or access to the Notice of Privacy Practices and understand that I have the right to review the notice prior to signing a consent. I understand that the CLINIC reserves the right to change the Notice of