Please review the following information which includes:
You will be given the opportunity to review these forms again when you check in for your appointment, and at that time we will collect an electronic signature in acknowledgement of these policies
CONSENT FOR TREATMENT
General Information: The Bastyr Center for Natural Health (BCNH) is a teaching facility and has practitioners who do private practice also. Our teaching clinic has students studying at Bastyr University and integrates a number of medical treatment modalities. Our teaching clinic at BCNH uses a ‘Team Care’ approach where faculty supervisors and student clinicians work as a team to address your health concerns. Student clinicians, depending on their levels of experience, may observe or participate in the care provided but are always supervised by healthcare providers licensed in the State of Washington. Your medical history, treatment plan and progress is discussed (without identifying information) among other student clinicians for educational purposes at the clinic and evaluated by the supervising faculty for appropriateness and effectiveness. Due to the diversity of modalities offered at BCNH, your treatment may include any or all of the following general modalities: East Asian Medicine, Naturopathic Medicine, Physical Medicine, Homeopathy, Psychological Counseling and Nutritional Counseling. Some modalities may be used exclusively on some specialty shifts, but many BCNH clinic teams use multiple treatment modalities. All of our East Asian medical practitioner faculty are licensed in the State of Washington having completed graduate level training and national board certification. Please visit www.bastyrcenter.org for individual faculty biographies.
Methods, Procedures and Therapeutic Approaches: Clinicians may perform general diagnostic procedures, psychological counseling, lifestyle counseling, exercise prescriptions, acupuncture, ayurvedic services, topical treatments, herbal medicine, natural medicine, dietary advice and therapeutic nutritional counseling, soft tissue and osseous manipulation, electromagnetic and thermal therapies.
Clinicians may performs any of the following procedures as necessary to give proper assessments, determine treatment approaches, treat or otherwise address your health concerns.
- General Diagnostic Procedures: including but not limited to venipuncture, pap smears, radiography, and blood and urine lab work, general physical exams, neurological and musculoskeletal assessments.
- Psychological Counseling; Lifestyle Counseling; Exercise Prescriptions
- Acupuncture: insertion of special sterilized needles or lancets at specific points on the body.
- Topical Treatments and Prepping: includes cupping (a technique using glass cups on the surface of the skin with usually a heat-created vacuum), and Gua Sha (rubbing on an area of the body with a blunt, round instrument).
- Herbs/Natural Medicines: prescribing therapeutic substances which include plants, minerals and animal materials. Substances may be given in the form of teas, pills, powders, tinctures (may contain alcohol); topical creams, pastes, plasters, washes; suppositories or other forms. Homeopathic remedies, often highly diluted quantities of naturally occurring substances, may also be used.
- Dietary Advice and Therapeutic Nutrition: use of foods, diet plans or nutritional supplements for treatment—may include intramuscular vitamin injections.
- Soft Tissue and Osseous Manipulation: use of massage, neuro-muscular techniques, muscle energy stretching or visceral manipulation, as well as manipulations of the extremities and spine including traction and craniosacral therapy.
- Electromagnetic and Thermal Therapies: includes the use of ultrasound, low and high volt electrical muscle stimulation, transcutaneous electrical stimulation, microcurrent stimulation, diathermy and infrared and ultraviolet therapies or moxa (warming or indirect burning of an acupuncture point and hydrotherapies).
- Potential Risks: While not common, can potentially occur from any therapy. Some examples include but are not limited to: pain, discomfort, blistering, discolorations, infection, or burns from topical procedures, heat or frictional therapies, electromagnetic- and hydrotherapies; loss of consciousness or deep tissue injury from needle insertions or needle breakage; allergic reactions to prescribed herbs or supplements; soft tissue or bone injury from physical manipulations; and aggravation of pre-existing symptoms. In addition, the patient must inform the East Asian medicine practitioner if the patient has a severe bleeding disorder or pacemaker prior to any treatment.
- Potential benefits: Restoration of health and the body’s maximal functional capacity, relief of pain and symptoms of disease, assistance in injury and disease recovery and prevention of a disease or its progression.
- Notice to Pregnant Women: All female patients must alert the doctor if they know or suspect that they are pregnant, since some of the therapies used could present a risk to the pregnancy.
I understand that Washington State law does not authorize naturopaths to treat me for any cancer or malignancy and that I am required to be under the care of a medical doctor or osteopathic physician (oncologist) while receiving care at the Bastyr Center for Natural Health. I recognize that I am here for supportive therapies only.
I understand that I may ask questions regarding my treatment before signing this form and that I am free to withdraw my consent and to discontinue participation in these procedures at any time. With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by the Bastyr Center for Natural Health or any of its personnel regarding cure or improvement of my condition. I understand that a record will be kept of the health services provided to me. I hereby acknowledge that I am financially responsible for services rendered.
FINANCIAL AGREEMENT
What you should know:
By signing this agreement you have agreed to pay for your services either by self-pay or using insurance benefits that cover the services you receive. If you don’t have insurance we have many discounted contracts you may qualify for, please ask us.
Health insurance is a contract between you and your insurance company. It’s best if you know which services your insurance will cover before you receive care. That way, there are no surprises for either of us. If you are not sure about your coverage, please ask your insurance company. Refer to the back of your insurance card.
Nonpayment
If you have not paid your bills within 30 days after receiving your final notice you will be turned over to collection agency, Professional Credit Services. You will be responsible for any collection agency fees that apply. If you have large unpaid balances and make no arrangement or payments you may be reported to a credit bureau and denied additional services at Bastyr. If this happens we can help you transfer your care.
Insurance billing
- Contract coverage: Bastyr contracts with many insurance plans. If we are in your health plan’s network, you are expected to pay any cost shares at the time of service
- Non-contracted: If your insurance plan is not contracted with Bastyr we will bill your insurance as a courtesy to you. You are responsible for the full cost of care. If your insurance does not pay within 45 days, the balance will be billed to you.
Care or services not covered by your insurance plan
Bastyr has many services that are non- covered by insurance plans. Some services might be considered experimental for research purposes only by your insurance company. If that is the case, you will be responsible for the full cost. We expect payment at the time of the service.
Returned Checks
Bastyr charges $28.00 for any returned checks.
Questions? Please contact our Billing Office at 206-834-4183, if you have any questions about anything in our policy.
PATIENT CANCELLATION AND NO SHOW AGREEMENT
Welcome to Bastyr Center for Natural Health. We are glad you have made an appointment for yourself or a family member.
To provide you with high-quality care, it is important for you to keep your scheduled appointment with the medical provider. Valuable time has been reserved for you or your family member. A missed appointment or late cancellation results in lost time that could have been given to another person wanting to receive care.
- Patients arriving more than 15 minutes late to their appointment will be subject to the providers’ discretion as to whether they can be seen. Late arrivals may also be subject to an abbreviated visit.
- If a patient cannot be seen, or is more than 20 minutes late for a scheduled visit, it will automatically be considered a no show.
You will receive a reminder call two days ahead to remind you of your appointment; however, it is your responsibility to keep record of your appointment and to arrive on time. If you need to cancel or reschedule your appointment, please call 24 hours in advance. You may also leave a message with our scheduling desk. Every late cancel/no-show will be recorded in your chart. Multiple late cancels and no-shows can end your ability to make advance appointments or receive care at Bastyr Center.
We realize that an emergency may occur and/or you may not be able to notify us. We will discuss that situation with you when it happens.
- After One (1) Late Cancel/No Show: You will be reminded of our Late Cancel/No Show policy.
- After Two (2) Late Cancels/No Shows: There will be a charge of $40 for appointments in Team Care, or $60 for appointments in Practitioner Care. (Bastyr Students will be charged $30.)
- After Three (3) Late Cancels/No Shows: Advanced scheduling privileges will be suspended for three months. You can still be seen on a same-day scheduling basis only, depending on provider availability. We cannot guarantee that you will be seen.
Thank you for working with us to ensure that services are provided to all our patients in the best possible way.
NOTICE OF PRIVACY PRACTICES
Acknowledgement
Bastyr Center for Natural Health is required to provide you with a copy of its Notice of Privacy Practices and to obtain written acknowledgement, if possible, that you have received it. You can review our privacy policies here. A parent or guardian should sign for patient under age 18. If you have questions concerning the management of your healthcare information at our clinic, or if you wish schedule an appointment to view your medical record, please call our medical records office at (206) 834-4151.