In the event that you must cancel an appointment, please give us the courtesy of as much notice as you can, but at least 24 hours notice. We will try to reschedule your appointment for the same week so that you don't miss your treatment. You will be charged the full fee for your session if you do not show up for your appointment or cancel your appointment with less than 24 hours notice.

Late Policy

If you are going to be late, please call and let us know and we will wait until the time we agree upon. If you do not give notice, we will wait 15 minutes beyond the start time of your appointment. If you have not arrived by then your appointment will be canceled and you will be responsible for the full payment of the session.

Emails

You may email us when necessary and we will respond as soon as possible, or within 48 hours. We are generally unavailable on weekends.

Confidentiality and Privacy Practices

As a healthcare provider, we are required by law to maintain and protect the confidentiality of your health information. You must give us written consent to waive this confidentiality. Exceptions to this rule are strictly limited to defined situations that include emergency care, quality assurance activities, public health, research, law enforcement activities, obtaining payment from third-party payers, and in consultation with other healthcare professionals. Any other disclosures for the purposes of treatment, payment or practice operations will be made only after obtaining your consent. Your rights to privacy regarding your protected health information:

• You may request restrictions on your disclosures.
• You may inspect and receive copies of your records within 30 days with a request.
• You may request to view changes to your records.

Please note that we may contact you for appointment reminders, birthdays & seasonal greetings, announcements and to inform you about our practice and its staff.

Fees

It is our policy that you pay the entire session fee or co-pay at the time of each session. If you would like to arrange another payment option, please discuss it with us. We will provide a minimum of one month's notice of any changes to our fees.

We are partners in your healthcare

Your participation in your healing process is crucial. Our goal is to get you well as soon as possible, which requires that you apply our health recommendations and comply with our treatment plan.

Agreement

I have read and understood the clinic's policies. I agree to all of the above treatment terms and conditions. 위 약관을 읽고 이해하였으며 모두 동의합니다.

Welcome to our office! The information below is provided to make you aware that our fees are different if you are a cash paying patient versus if you have insurance, a personal injury (auto accident) or worker's compensation case.

Insurance Patients

You will be responsible for payment of any deductibles, co-pays, and co-insurance amounts not covered by your insurance provider (the amount of these costs varies). Please note that we usually charge insurance companies between $250–510 per visit, depending on the therapies performed in conjunction with the acupuncture, such as: manual therapy (massage), infrared, e-stim, moxibustion, therapeutic exercises, etc. Charges are often higher for new patient visits or re-evaluations of your case. We rarely receive what we bill since all charges are reviewed and reduced by insurance companies. When you receive your explanation of billing (EOB) from your insurance company, it may tell you that you owe Pure Wave Medical Group Inc the difference between what we charged for your visit and what your insurance actually paid. This is not necessarily the case. We will inform you if we will need to collect this balance or a portion of it (we usually do not).

There may be times when our billing service is mis-quoted information and payment is not made as initially described by your insurance. These additional amounts are your responsibility and we will do our best to keep you apprised of any information regarding your benefits if they should change. Feel free to contact our billing service any time if you have questions about billing your insurance for acupuncture: (714) 681-2785.

Cash Patients

Currently our cash rate for First visit (thorough exam, treatment, and report of findings) is $150 and follow-up visit is $100. These fees are called "point of service fees" as they are paid at the time services are delivered. Understand that this is also a discounted fee because it does not involve the administration and processing of insurance, and because we know most people are unable to pay our regular fees that we bill insurance companies. Since this is a discounted rate off of our usual fees, if, at any time, you have any other coverage either through insurance, an auto accident, or worker's compensation claim, please notify our office immediately so that we can make efforts to receive our regular rates. We have a few sliding-scale spots available in our practice and are reserved for those with financial hardship/low-income that display a strong commitment to improving their health.

Worker's Compensation (injury on the job) and Auto Accident Cases

Patients are not usually responsible for any costs associated with a worker's comp or auto accident claim with the exception of herbs/supplements. Please speak directly with our billing service about your case and provide your adjuster's information. The fees charged are our standard rates for third-party payers, which are dependent on the therapies you receive with your treatment. If for any reason we are denied payment, you will be responsible for payment on the account (a plan that works with your budget can be devised).

All fees charged at Pure Wave Medical Group Inc are reasonable and in keeping with industry standards.

Herbal and Nutritional Supplements are NOT covered by insurance or third party payers and must be paid at the time these items are received.

I have read and understood the fees charged at Pure Wave Medical Group Inc. 위 수가 안내를 읽고 이해하였습니다.

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.

I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I understand that the herbs may be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs.

I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment.

I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant.

While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed.

I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.

By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

I hereby request and consent to the performance of massage therapy and bodywork procedures on me (or on the patient named below, for whom I am legally responsible) by the massage therapist(s) and clinical staff who now or in the future treat me while employed by, working or associated with or serving as back-up for the clinic listed below, whether signatories to this form or not.

I understand that massage therapy may include, but is not limited to, Swedish massage, deep tissue massage, trigger point therapy, myofascial release, manual therapy, range-of-motion and stretching, and the application of heat, cold, or topical preparations. The therapist may use hands, forearms, or handheld tools, and may work through clothing or with appropriate draping. Massage therapy is provided for general relaxation, stress reduction, relief of muscular tension, and improvement of circulation and mobility, and as supportive care in conjunction with acupuncture and other treatments in this office.

I have been informed that massage therapy is generally safe, but that it may have some side effects, including temporary soreness, tenderness, bruising, redness, or inflammation in the treated areas, and occasionally lightheadedness or fatigue. These effects are usually mild and short-lived. Deep tissue and trigger point work may cause more pronounced soreness for a day or two.

I understand that there are certain conditions for which massage may be inappropriate or require modification, including but not limited to: fever or acute infection, contagious skin conditions, recent surgery or injury, fractures, blood clots or clotting disorders, uncontrolled high blood pressure, certain cancers, and pregnancy. I agree to inform the therapist of all known medical conditions, medications, allergies, areas of injury or sensitivity, and if I am or may be pregnant, and to keep this information current. I understand that the therapist is not qualified to perform any spinal manipulations or adjustments, or to diagnose or prescribe for any illness.

I understand that massage therapy is not a substitute for medical examination, diagnosis, or treatment, and that I should see a physician or other qualified health care provider for any physical or mental ailment of which I am aware.

I understand that the massage will be performed in a professional manner and that draping will be used at all times to protect my privacy and comfort. I understand that the massage therapy provided is strictly non-sexual, and that any sexual remarks or advances by either party will result in immediate termination of the session. I understand that I may stop the treatment at any time, and I will communicate any discomfort during the session so that pressure or technique can be adjusted.

I understand the clinical and administrative staff may review my patient records, but all my records will be kept confidential and will not be released without my written consent, except as required or permitted by law.

By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of massage therapy, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek massage therapy at this office.