MARIA MORACA, LAC OFFICE POLICIES
Your session fees are payable with cash, check or card, and due at the time of service.
If you have insurance coverage for acupuncture, I’ll give you a bill for you to submit to your provider.
All sessions are by appointment; no walk-ins.
When re-scheduling or canceling, please give 24 hours notice.
I reserve the right to charge for any sessions that are re-scheduled or cancelled with less then 24 hours notice.
I reserve the right to end my therapeutic relationship with any patient who cancels appointments with short notice, or a patient who no-shows.
Consent for Purposes of Treatment, Payment and Health Care Operation
With my electronic signature, I consent to the use or disclosure of my identifiable health information by Maria Moraca, LAc (hereafter noted as MM) for the purposes of evaluation, providing treatment to, obtaining payment for my health care bills, or to conduct health care operations. I understand that evaluation or treatment of me at MM may be conditioned upon my consent as evidenced by my electronic signature on this document.
I understand I have the right to request a restriction as to how my identifiable health information is used or disclosed to carry out treatment, payment or health care operations of the practice. MM is not required to agree to the restrictions that I may request. However, if MM agrees to a restriction that I request, the restriction is binding upon MM. I have the right to revoke this consent, in writing, at any time except to the extent that MM has taken action in reliance on this consent.
My identifiable health information means health information, including my demographic information, collected from me and created or received by my practitioner, another health care provider, a health plan, my employer or a health care clearinghouse. This identifiable health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I understand I have the right to review MM’s Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices 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 MM. This Notice of Privacy Practices also describes my rights and the duties of my practitioners with respect to my identifiable health information.
Maria Moraca, LAc reserves the right to change information contained in the Notice of Privacy Practices at any time. I may obtain a revised Notice of Privacy Practices by requesting the most current notice during any office visit.
Please sign using a stylus, your mouse, or your finger below to authorize this contract. By electronically signing this document, you agree to the terms established above.
After the document is signed, you can proceed to print it or save it as a PDF.