CLINIC FORMS

Click the link below to download and print our medical forms. Please fill out and sign prior to coming in.
Medical Forms
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IF COMPLETING FORMS ONLINE: 
PATIENT SIGNATURES MUST BE SIGNED AT APPOINTMENT

    Lance Lee - Acupuncture Medical Associates - Medical Forms

    GENERAL INFORMATION

    FOCUS

    SYMPTOMS

    FEMALE CONCERNS

    MEDICAL HISTORY

    PAIN

    NEUROLOGICAL - PSYCHOLOGICAL 

    FAMILY HEALTH HISTORY

    Please provide details of any family members who have had any of the following conditions.
    Please sign and date at your next appointment.

    INSURANCE
    If the insurance company decides not to pay, the charges are the responsibility of the patient.
    ​Please sign and date at your next appointment.
    I agree to pay if the insurance does not pay.
    To be completed by an Acupuncture Medical Associates Representative.

    ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

    I have read, understand and have been provided with a copy of Notice of Privacy Practices that provides a more complete description of information and disclosures practice of Acupuncture Medical. I understand that i have the following rights and privileges. 
    • The right to review the notice prior to signing this consent
    • The right to object to the use of my health information for directory purposes, and
    • The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations
    DISCLAIMER: The Acupuncture Medical Notice of Privacy Practice is subject to change. If we change our notice, you may obtain a copy of the revised notice by requesting a hard copy from the Privacy Practice officer Leesa M. Lee.

    Privacy Officer Contact Information 
    2800 N. Grimes
    Hobbs, NM 88240
    (575) 392-2712

    By signing this form, I acknowledge receipt of the Notice of Privacy Practices of Acupuncture Medical Associates, LLC.
    INABILITY TO OBTAIN ACKNOWLEDGEMENT:
    • To be completed only if no signature is obtained. If it is not possible to obtain the individual's acknowledgement was not obtained:
    • Patient unable to sign
    • Patient unable to sign (inactive patient)
    • Family/significant other not available
    • Patient declines to sign
    • Other  ​                                                                                                                                                                                                                    

    ACUPUNCTURE MEDICAL ASSOCIATES, LLC
    ​HEALTH CARE AUTHORIZATION FORM
    THE PATIENT IDENTIFIED ABOVE AUTHORIZES ACUPUNCTURE MEDICAL TO USE AND/OR DISCLOSE PROTECTED HEALTH INFORMATION IN ACCORDANCE WITH THE FOLLOWING:

    SPECIFIC AUTHORIZATION
    • I give permission to Acupuncture Medical to use my address, phone number, and clinical records to contact me with appointment reminders, missed appointment notification, birthday cards, holiday related cards, information about treatment alternatives or other health related information.
    • If Acupuncture Medical contacts me by phone, I give them permission to leave a phone message on my answering machine or voice mail.
    • (OPEN ROOM AUTHORIZATION - OPTIONAL) I give Acupuncture Medical permission to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear at any time in private, the doctor will provide a room for these conversations. 
    • By signing this form you are giving Acupuncture Medical permission to use the disclose your protected health information in accordance with the directives listed.

    RIGHT TO REVOKE AUTHORIZATION 
    You have the right to revoke the AUTHORIZATION, in writing at any time. However, your written request to revoke this AUTHORIZATION is not effective to the extent that we have provided services or taken action in reliance on your authorization. 

    You may revoke this AUTHORIZATION by mailing or hand delivering a written notice to the Privacy Official of Acupuncture Medical. The written notice must contain the following information.
    • Name
    • Social Security Number
    • Date of Birth
    • A clear statement of your intent to revoke this AUTHORIZATION 
    • The date of your request
    • Your signature
    The revocation is not effective until it is received by the Privacy Official.
    The AUTHORIZATION is requested by Acupuncture Medical for its own use/disclosure of PHI. (Minimum necessary standards apply.)
    You have the right to refuse to sign this AUTHORIZATION. If you refuse to sign this AUTHORIZATION, Acupuncture Medical will not refuse to provide treatment.
    You have the right to inspect or copy the PHI to be used/disclosed.

    ******A COPY OF THIS SIGNED AUTHORIZATION WILL BE PROVIDED TO YOU UPON REQUEST*****

    ​
    ​Please sign your next appointment.