By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Material Medical by Lindsey Rosso McKoy at Broomfield Community Acupuncture. I understand that acupuncturists practicing in the state of Colorado are not primary care providers and that regular primary care by a licensed physician is strongly recommended by this clinic’s practitioner. I understand that there may be other treatment alternatives, including treatment offered by a licensed physician. I consent to the use of my identifiable health information by Broomfield Community Acupuncture for the purposes of diagnosis or providing treatment to, obtaining payment for my health care bills or to conduct health care operations.

Acupuncture / Moxibustion: I understand that acupuncture is performed by the insertion of needles through the skin or by the application of heat to the skin (or both) at certain points on or near the surface of the body in an attempt to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result. These could include but are not limited to local bruising, minor bleeding, fainting, pain or discomfort, and the possible aggravation of symptoms existing prior to acupuncture treatment. I understand that moxibustion (an herbal heat therapy) carries a risk of burning or scarring from its use. I understand that I may refuse these therapies. I understand that no guarantees concerning its use and effects are given to me and that I am free to stop treatment at any time.

Chinese Herbs: I understand that substances from the Oriental Material Medical may be recommended to me to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body’s physiological functions. I understand that I am not required to take these substances but must follow the directions for administration and dosage if I do decide to take them. I am aware that certain adverse side effect may result from taking these substances. These could include but are not limited to: changes in bowel movement, abdominal pain or discomfort, and the possible aggravation of symptoms existing prior to herbal treatment. Should I experience any problems, which I associate with these substances, I should suspend taking them and call Broomfield Community Acupuncture as soon as possible.

Acupressure / Massage: I understand that I may also be given acupressure/massage as part of my treatment to modify or prevent pain perception and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result from this treatment. These could include but are not limited to bruising, sore muscles or aches, and the possible aggravation of symptoms existing prior to treatment. I understand that I may stop the treatment if it is too uncomfortable.

Electro-Acupuncture: I understand that I may be asked to have electro-acupuncture administered with the acupuncture. I am aware that certain adverse side effects may result. These may include but are not limited to electrical shock, pain or discomfort, and the possible aggravation of symptoms existing prior to treatment. I understand that I may refuse this treatment.

Privacy Practices / Health Information Privacy Protection Act (HIPPA) Compliance:

I have reviewed the Broomfield Community Acupuncture, Notice of Privacy Practices prior to signing this document. This notice describes the types of uses and disclosures of my identifiable health information that will occur in my treatment, payment of my bills, or in the performance of health care operations of the Broomfield Community Acupuncture.

Broomfield Community Acupuncture reserves the right to change information contained in the Notice of Privacy Practices at any time, in concordance with HIPPA. I may obtain a revised Notice of Privacy Practices at any time by requesting the most current notice in writing or in person at the time of my office visit.

Financial Policies / Payments

Payment is expected in full at time of service. We accept cash and check, credit cards, including Flex Spending Account (FSA) cards.

There is a $40 fee for returned checks, with an additional $40 fee charged each additional week that the account is not cleared of the bad check.

Cancellation Policy

Broomfield Community Acupuncture requires at least 24 hours notice of cancellation in advance of the scheduled appointment time. Missed appointments without notification and cancellations with less than 24 hours notice will be charged the full fee visit.

Insurance Billing

We are unable to bill insurance. Upon request, an invoice can be produced which may be submitted to insurance companies for reimbursement by the patient.

• I agree to pay for services rendered at the time of service. I acknowledge that I may request the fees for various procedures before they occur and include that information in my decision regarding health care.
• I understand that this office requires notice of cancellation at least 24 hours in advance of the scheduled appointment time.
• I consent to treatment as agreed upon between the practitioner and myself. Any therapy will proceed only with our mutual consent. I agree to discuss any problems in my care with the practitioner.

COLORADO MANDATORY DISCLOSURE STATEMENT

Education and Experience

Lindsey Rosso McKoy, L.Ac. earned her Masters of Acupuncture and Oriental Medicine degree from the Oregon College of Oriental Medicine in 2007. This three-year program consists of 3,116 hours of education including 948 hours of clinical practice. She was certified as a Diplomatic in Acupuncture and Oriental Medicine by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) in September 2007. This includes certification in Clean Needle Technique and Chinese Herbology.

Lindsey’s training includes adjunctive therapies such as moxibustion, Zen Shiatsu, cupping, gua sha, auriculotherapy, and dietary and lifestyle recommendations.

Lindsey is a registered acupuncturist in Colorado. This license has never been suspended or revoked.

Broomfield Community Acupuncture, LLC complies with the rules and regulations promulgated by the Colorado Department of Health, including the proper cleaning and sterilization of needles and the sanitation of acupuncture offices. Only single-use, disposable, factory-sterilized needles are utilized.

Fee Schedule

Initial Intake Fee	$15
Community Acupuncture Treatments	$65-85 on a sliding scale
Herbal Consultation without acupuncture	$65-85 on a sliding scale
Cupping adjunct treatment after acupuncture	$15 per visit
Cost of herbs are not included in the rates stated above.

Patient’s Rights

• The patient is entitled to receive information about the methods of therapy, the techniques used, and the duration of therapy, if known.
• The patient may seek a second opinion from another health care professional or may terminate therapy at any time.
• In a professional relationship, sexual intimacy is never appropriate and should be reported to the Director of the Division of Registrations in the Department of Regulatory Agencies.

The practice of acupuncture is regulated by the Director of Registrations, Colorado Department of Regulatory Agencies. If you have comments, questions, or complaints, contact the Acupuncturists Registration Office, 1560 Broadway, Suite 1350, Denver, Colorado, 80202. Telephone (303) 894-2440