BLUE HERON HEALTH
Traditional Chinese Medicine
445 Dewey Avenue, Boulder, Colorado 80304 Tel: 303-442-4973
Acupuncture and Chinese Herbal Medicine
Acupuncture consists of the insertion of very fine needles into the skin at specific points on the body in order to affect the energy flow and restore health. Chinese herbs are typically prepared as teas or taken as pills several times a day. In addition we utilize dietary counseling, massage, electrical stimulation, cupping, and moxibustion (the burning of a specific herb) over affected areas of the body to enhance your treatment. Your initial consultation and treatment will last about 1 1/2 hours. Subsequent treatments will last 45 minutes to 1 hour.
Duration and frequency of treatment varies with each individual and the condition being treated. Generally, a course of treatment consists of five to ten visits. You can expect to come once a week, tapering down to once every two weeks or once a month. for acute conditions you may need to come more than once a week. Many people like to schedule appointments occasionally or even regularly for preventive care, for stress reduction, or during the change of seasons.
Acupuncture stimulates and reharmonizes the energy of the body. People often feel calmer and more energized. After treatment it is not unusual to feel increased energy or to have the opposite reaction, to feel tired for a day. Occasionally patients report that their symptoms are exaggerated for a day or two and then show improvement. Acupuncture is an extremely safe and reliable healthcare medium when administered by a licensed practitioner. However, on rare occasions problems have occurred. These problems may be serious and include damage to nerves, injury to arteries, collapse of a lung, infection at the site of needle insertion, and broken needle. Your signature on this disclosure form indicates that you understand the possible risks associated with acupuncture and accept full responsibility for them.
In conjunction with your treatment the following suggestions are offered. Arrive for treatment neither hungry nor full. Don�t eat for about 1/2 hour after a treatment. Avoid unusually strenuous exercise following an acupuncture treatment. If you have been treated for musculoskeletal pain keep the treated area warm.
Fees and Office Policy
New Patient Evaluation $100
Regular Office Visit $70
Please make arrangements to pay for your visit on the date of service. We regret we are unable to process insurance claims or accept postdated checks.
24 Hour Cancellation Notice: Please notify us at least 24 hours in advance if you need to cancel your appointment. You will be expected to pay for late or no notice cancellations. Please try to be on time for your appointment, and be aware that if you are late your treatment may need to be shortened so as to keep other clients waiting throughout the day. Exceptions will be made for emergency situations.
Educational and Professional Experience
Jan Vanderlinden, Lic. Ac., Dipl Ac (NCCAOM), R.CST., M.S., M.F.A.
No license, certificate or registration in acupuncture or any other health care profession issued to Jan Vanderlinden by any local, state or national health care agency has ever been suspended or revoked.
BLUE HERON HEALTH
Rights of the Patient
We are in full compliance with the rules and regulations of the Colorado Departmentof Health, including those related to the proper sterilization of needles and the sanitation ofour premises. The practice of acupuncture is regulated by the Department of Regulatory Agencies of the State of Colorado. If you have any further questions regarding the regulation of acupuncturist, please contact the Office of Acupuncturists Registration at 1560 Broadway, Suite #680, Denver, Colorado 80202 or telephone 303-894-2464.
Patient Signature:_________________________________ Date:_______________
Practitioner Signature:______________________________
BLUE HERON HEALTH
Notice of Health Information Practices
This notice describes how information about patients may be used by this office and how patients may get access to this information. Please read it carefully. Our clinic is committed to using personal health care information responsibly. Each time a patient receives a treatment a record is made of this visit. it contains information on symptoms, diagnosis and treatment. This information serves as a basis for planning care and future treatments. It may also serve the following purposes:
Although your health record is the physical property of Blue Heron Health the information in it belongs to you. You have the right to obtain a paper copy of this notice upon request; to inspect and copy the health recored (a fee may be assessed); request an amendment of the health record; obtain a list of disclosures of the record; request a restriction on certain uses and disclosures of your record; and revoke your authorization to disclose information except to the extent that action has already been taken.
Blue Heron Health is required to maintain the privacy of your record, provide you with this notice of our privacy practice and abide by its terms. We are also required to notify patients if we are unable to agree to a requested restriction in your record. We will not use or disclose health information without authorization except as described in this notice. We will discontinue to disclose information after receipt of a written revocation of authorization. We will provide information without authorization if necessary to continue treatment of the patient or receive reimbursement for services.
If you want additional information or believe your privacy rights have been violated you may contact Blue Heron Health, or the Office for Civil Rights, US Department of Health and Human Services, 200 Independence Ave., S.W. Room 509F, HHH Bldg., Washington D.C. 20201.
Patients Signature______________________________________________________
Date__________________________