New Patient Form Packet
The following form packet is available for you to download in advance, fill out and either email back, or bring to the office for your first visit. Forms included are:
* Please Note: If you are unable to print - out the forms, please show-up for your appointment 30 minutes early to complete the required documents. Also, if you have any recent lab work it's helpful to bring this in on your first visit.
Authorization For Release or Disclosure of Medical Information
Use this form if you would like your medical information and protected health information (PHI) to be released from Healing Lotus Acupuncture to another practitioner, insurance company, yourself, or another entity as specified by you.
Authorization For Release of Medical Records
Use this form to request the release of medical records from a physician to Healing Lotus Acupuncture.
A Message to Our Patients About Arbitration
As part of our informed consent, which you will receive in the office, their is an attached arbitration agreement. By signing this agreement we are agreeing that any dispute arising out of the medical services you receive is to be resolved in binding arbitration rather than a suit in court. Lawsuits are something no one anticipates and everyone hopes to avoid. We believe that the method of resolving disputes by arbitration is one of the fairest systems for both patients and physicians. Arbitration agreements between health care providers and their patients have long been recognized and approved by your state courts.
By signing this agreement you are changing the place where your claim will be presented. You still can call witnesses and present evidence. Each party selects an arbitrator (party arbitrators), who then select a third, neutral arbitrator. This agreement generally helps to limit the legal costs for both patients and physicians. This is because the time to conduct an arbitration hearing is far less than for a jury trial. Further, both parties are spared some of the rigors of trial and the publicity which may accompany judicial proceedings.
Our goal, of course, is to provide you with quality medical care which fully meets your health care needs. We know that most problems begin with communication. Therefore, if you have any questions about your care, please contact us.
4300 12th Ave
Moline, IL 61265
M - F: 8am - 6pm
Sat.: 10am - 3pm