New Patient Forms:
Before your first visit to KMA, you must review our office policies and fill out the following digital forms through our HIPAA compliant EHR. If you prefer to use paper copies of these forms, please notify the office prior to your appointment time. Treatment will not begin until all forms are completed and signed.
1) Patient Contact and Informed Consent : This form contains all of our office policies regarding treatment, payment for services, cancellations, and possible adverse effects.
If you would like us to verify your insurance benefits for acupuncture services, you must enter policy information when you fill out this form. Please have this information on hand before you begin the form. You will be responsible for paying the full price of services if we have not been able to verify your insurance benefits.
Please carefully read over this form. A copy of your responses will be emailed to you once you have submitted this form. *If the patient is under the age of 18, a legal guardian should complete this form on behalf of the minor.
Please review our HIPAA Privacy Statement prior to your first appointment: KMA HIPAA Notice for Patients. Our Informed Consent form indicates that you have read and agree to our HIPAA Privacy policies. You may request that we print the HIPAA Privacy Statement for you. Please notify us prior to your arrival if you would like us to print this notice for your records.
2) New Patient Health Intake Form : Our comprehensive Health Intake Form is designed to allow us to craft a detailed treatment plan specific to your needs. This is a lengthy form and will ask you about current medications, supplements, and health history, so please have this information on hand before you begin. Give yourself time to complete it entirely.
Financial Forms:
Maryland law allows us to provide pre-payment discount packages for out of pocket medical services such as acupuncture and massage. If you wish to take advantage of our pre-payment services, please print, read, and sign the following form prior to your arrival. You will need to initial each paragraph to indicate that you understand the conditions of the package.