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Patient Demographic


Primary Insurance Information

Secondary Insurance Information

Emergency Contact


Trauma History

What are the three most traumatic things you have experienced?

Physical History

Have you experienced chronic, unexplained physical ailments?
Bournemouth Questionnaire

Instructions: The following scales have been designed to find out about your painful complaint & how it is affecting you. Please answer ALL the scales, and mark the ONE number on EACH scale that best describes how you feel.

1.Over the past few days, on average, how would you rate your pain? 1 No pain - 10 Worst pain possible
2.Over the past few days, on average, how has your complaint interfered with your daily activities (housework, washing, dressing, lifting, walking, reading, driving, climbing stairs, getting in/out of bed/chair, sleeping)?
3.Over the past few days, on average, how much has your painful complaint interfered with your normal social routine including recreational, social and family activities?
4.Over the past few days, on average, how anxious (uptight, tense, irritable, difficulty in relaxing/concentrating)have you been feeling?
5.Over the past few days, how depressed (down-in-the-dumps, sad, in low spirits, pessimistic, lethargic) have you been feeling?
6.Over the past few days, how do you think your work (both inside the home and/or employed work) have affected your painful complaint?
7.Over the past few days, on average, how much have you been able to control (help/reduce) and cope with your pain on your own?
Metabolic Assessment Form

Part 1

Please list the 5 major health concerns in your order of importance:

Metabolic Assessment Form

This notice describes how medical information about you may be used and disclosed, and how you can gain access to this information. Please review it carefully.

Protected Health Information (PHI), about you, is maintained as a written and/or electronic record of your contacts or visits for healthcare services with Holistic Elite. Specifically, PHI is information about you, including demographic information (i.e., name, address, phone, etc, that may identify you and relates to your past, present or future physical or mental health condition and related healthcare services.

Holistic Elite is required to follow specific rules on maintaining the confidentiality of your PHI, using your information, and disclosing or sharing this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your PHI. It also describes how we follow applicable rules and use and disclose your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law.

Your Health Information Rights

Inspect and Copy: You have the right to inspect and copy the protected health information that we maintain about you in our designated record set for as long as we maintain that information. This designated record set includes your medical and billing records, as well as any other records we use for making any decision about you. Any psychotherapy notes that may have been included in records we received about you are not available for your inspection or copying by law. We may charge you a fee for the costs of copying, mailing, or other supplies used in fulfilling your request.

If you wish to inspect or copy your medical information, you must submit your request in writing to our practice manager. You may mail in your request or bring it to our office. We will have 30 days to respond to your request for information that we maintain at our practice site. If the information is stored offsite, we are allowed up to 60 days to respond but must inform you of this delay.

Request Amendment: You have the right to request that we amend your medical information if you feel that it is incomplete or inaccurate. You must make this request in writing to our practice manager, stating exactly what information is incomplete or inaccurate and the reasoning that supports your request. We will respond in writing within 60 days of your request.

We are permitted to deny your request if it is not in writing or does not include a reason to support the request. We may also deny your request if:

• The information was not created by us, or the person who created it is no longer available to make the amendment
• The information is not part of the record which you are permitted to inspect and copy
• The information is not part of the designated record set kept by this practice; or if it is the opinion of the health care provider that the information is accurate and complete.

We will respond within 60 days, in writing, explaining of the request was accepted or denied.

Request an alternative means of confidential communication: You have the right to ask us to contact you about medical matters using an alternative method (i.e., email, telephone), and to a destination (i.e., cell phone number, alternative address, etc.) designated by you. You must inform us in writing, {using a form provided by our practice}, how you wish to be contacted if other than the address/phone number that we have on file. We will follow all reasonable requests.

Request a restriction of your PHI: This means you have the right to ask us, in writing, not to use or disclose any part of your Protected Health Information for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases, we may deny your request for a restriction. You will have the right to request, in writing, that we restrict communication to your health plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction.

An accounting of Disclosure: You have the right to request a list of the disclosures of your health information we have made outside of our practice that were not for treatment, payment, or health care operations. Your request must be made in writing and must state the time period for the requested information. You may not request information for any dates greater than six years (our legal obligation to retain information).

Your first request for a list of disclosures within a 12month period will be free. If you request an additional list within 12months of the first request, we may charge you a fee for the costs of providing the subsequent list. We will accommodate all reasonable requests.

A Paper copy of This Notice: You have the right to receive a paper copy of this notice upon request. You may obtain a copy by asking our receptionist at your next visit by calling and asking us to mail you a copy.

File a Complaint: If you believe we have violated your medical information privacy rights, you have the right to file a complaint with us, or directly to the Secretary of Health and Human services.


U.S. Department of Health and Human Services 200 Independence Avenue, S.W.

Washington, D.C. 20201



Authorize other use and disclosure: You have the right to authorize any use or disclosure of PHI that is not specified within this notice. For example, we would need your written authorization to use or disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes, or if we intended to sell your PHI. You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider, or our practice, has taken an action in reliance on the use or disclosure indicated in the authorization.

We may contact you to provide information about health related benefits and services offered by our office, for fundraising activities, share information in a disaster relief situation, include your information in a hospital directory, or with respect to a group health plan, to disclose information to the health plan sponsor. You will have the right to opt out of such special notices, and each such notice will include instructions for opting out.

Ways in Which We May use and Disclose Your Protected Health Information

The following paragraphs describe different ways that we use and disclose your protected health information. We have provided an example for each category, but these examples are not meant to be exhaustive. We assure you that all of the ways we are permitted to use and disclose your health Information fall within one of these categories.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. We will also disclose your health information to other physicians who may be treating you. Additionally, we may from time to time disclose your health information to another physician whom we have requested to be involved in your care. For example, we should disclose your health information to a specialist to whom we have referred you for a diagnosis to help in your treatment.

Health care operations: We will use and disclose your protected health information to support the business activities of our practice. For example – we may use medical information about you to review and evaluate our treatment and services or to evaluate our staff’s performance while caring for you. In addition, we may disclose your health information to third-party business associates who perform billing, consulting, or transcription services for our practice.

Payment: We will use and disclose your protected health information to obtain payment for the health care services we provide you. For example, - we may include information with a bill to a third-party payer that identifies you, your diagnosis, procedures performed, and supplies used in rendering the service.


Other Ways We May Use and Disclose Your Protected Health Information


Public health: We will use and disclose your protected health information in certain situations to help with public health and safety issues. Some of the situations include:

  • Preventing disease

  • Helping with product recalls

  • Reporting adverse reactions to medications

  • Reporting suspected abuse, neglect, or domestic violence

  • Preventing or reducing a serious threat to anyone’s health or safety 

Research: We will use and disclose your protected health information to researchers provided the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

As Required by Law: We will use and disclose your protected health information when required to by federal, state, or local law. You will be notified of any such disclosures.

Other Permitted and Required Uses and Disclosures: We are also permitted to use or disclose your PHI without your written authorization for the following purposes:

  • To comply with Food and Drug Administration requirements

  • Legal proceedings

  • Coroners

  • Funeral directors

  • Organ donation

  • Criminal activity

  • Military activity

  • National security

  • Worker's compensation

  • When an inmate is in a correctional facility

  • If requested by the Department of Health and Human Services in order to investigate or determine our compliance with the requirements of the Privacy Rule.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

By signing this form, you acknowledge you were advised of the HIPAA Notice of Privacy Practices. Our HIPAA Notice of Privacy Practices provides information about how we may use and disclose your protected information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. You may request a copy of the Notice of Privacy.

Informed Consent for Acupuncture Treatment(s)

I do not expect the acupuncturist to be able to anticipate and explain all possible risks and complications. I will rely on the acupuncturist to exercise professional judgment during the course of the treatment, and to act in my best interest based on the available facts then known. If I become pregnant, I will notify the acupuncturist immediately.

I have read (or was read) the above consent for Acupuncture treatment, and my questions have been answered regarding its content.

By signing below, I agree to receive the above-named procedures, and any other techniques comprising Oriental Medicine. I understand that results are not guaranteed. I intend this consent form to cover the entire course of treatment for my present condition, and any future condition for which I may seek treatment.

Financial Policy

Thank you for choosing Holistic Elite as your health care provider. Please carefully read and Initial each statement and sign below. This policy has been put in place to ensure that financial payments due are recovered to allow us to continue to provide quality medical care for our patients. It is important that we work together to assure that payment for services is as simple and straightforward as possible. Our practice manager or billing department will be glad to discuss these policies with you. Please initial below:

2. I understand that Holistic Elite will collect all co-payments at the time of visit and any procedure deductibles and coinsurance up to an amount equal to payment in full for the planned procedure code. Payment in full and expected coinsurance payment responsibility are determined by the anticipated billing code(s), details of your Insurance policy, and agreement between your insurance company and Holistic Elite. Any over-payment to your account will be refunded to you at your request after payment and/or remittance has been received from your insurance company.

4. I understand that if I am unable to make a scheduled appointment, I need to contact Holistic Elite at least 24 hours before my scheduled appointment time. Due to a demand for appointments, missed appointments prevent us from scheduling appropriately and keep others in need from being seen. A $35 FEE WILL BE ASSESSED FOR ALL MISSED APPOINTMENTS NOT CANCELED WITH AT LEAST 24 HOURS ADVANCED NOTICE.

5. I understand that if my accounts not paid in full within 90 days of a statement date, a 35 collection agency processing fee will be added to the outstanding balance and will be turned over to collections for further processing. No additional appointments will be made for delinquent accounts until they are brought current.

6. Holistic Elite will allow 60 days from the date of filing for my Insurance company to process or pay a claim. State law allows insurance companies operating in the state no more than 60 days to process claims. It is my responsibility to provide my insurance company with requested Information needed to process a claim for services. It is also my responsibility to notify Holistic Elite if there is any change in my insurance coverage, residence, or phone number. ULTIMATELY, IT IS UP TO ME TO KNOW MY INSURANCE BENEFITS.

I have read and agree to all the provisions of the above financial policy. I understand that I am ultimately responsible for all professional fees incurred for professional services performed by the attending physician.I understand that I am ultimately responsible for all professional fees incurred for professional services performed by the attending physician.

Patient Health Information Consent Form

We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations, we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your PHI, we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. The patient understands and agrees to allow Holistic Elite to use their patient Health Information (PHI) for the purpose of treatment, payment healthcare operations, and coordination of care. As an example, the patient agrees to allow Holistic Elite office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment. Holistic Elite also explicitly requests the permission to send a thank you letter to the person that referred you. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Holistic Elite is not obligated to agree to those restrictions. A patient's written consent need only be obtained one time for all subsequent care given the patient in this office. The patient may provide a written request to revoke consent at any time during care. This would not affect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented. For your security and right to privacy, our staff has been trained in the area of patient record privacy and Holistic Elite has been designated a privacy official to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures. If the patient refuses to sign this consent for the purpose of treatment payment and health care operations, Holistic Elite has the right to refuse to give care. I have read and understand how my Patient Health Information will be used and I Agree to these policies and procedures.

Assignment of Benefits and Medical Release

, hereinafter ASSIGNOR, hereby authorize 

hereinafter ASSIGNEE, the medical benefits otherwise payable to me for their service, but not to exceed the changes of those services.  I hereby ASSIGN to ASSIGNEE any benefits or causes of action under any policy of insurance, indemnity agreement, or any other collateral source as defined in Florida Statutes for any service and or charges provided by ASSIGNEE.  This ASSIGNMENT OF BENEFITS is given in exchange for ASSIGNEE agreeing to await payment from the above named insurance carrier for all payments due and payable pursuant to the ASSIGNOR’S contract of insurance.  This ASSIGNMENT OF BENEFITS is IRREVOCABLE unless subsequent revocation is in writing and agreed to by both parties. 

This document shall be sufficient to authorize any person having records of medical treatment, services, or supplies pertaining to me, to release true copies of same to ASSIGNEE or any insurer providing coverage to me in connection with the processing of any claim for benefits made by me or by the ASSIGNEE herin.  A photocopy of this document shall be as binding as an original signature page.  The undersigned ASSIGNOR by these presents does give and grant the said ASSIGNEE as attorney the full power and authority to do and perform all and every act whatsoever requisite and necessary to be done in and about the premises as fully to all intents and purposes as the ASSIGNOR might or could personally present insofar as the endorsing and cashing of said checks are concerned as well as any other document. 

Form Submitted!

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