Method of Payment

Health Insurance

Motor Vehicle Accident (MVA) or Labor and Industry (LNI/Work Comp)

Are you currently receiving health care?

Successful health care and preventative medicine are only possible when the physician has a complete understanding of the patient physically, mentally and emotionally.
Please complete this questionnaire as thoroughly as possible.
Thank you.

For What Conditions Are you Seeking Care?


For this condition, do you have any past diagnosis? Have you received any imagine or other treatment?

2. Condition/Symptom

For this condition, do you have any past diagnosis? Have you received any imagine or other treatment?


For this condition, do you have any past diagnosis? Have you received any imagine or other treatment?

Wintzer Acupuncture New Patient Health History

Do you have any reason to believe that you are pregnant?

Do you have any chronic infectious diseases?

Are you currently suffering from any chronic illness?

Please check any of the following medications that you are currently taking or have taken in the last 12 months:

Childhood or Adult Illnesses

Please check any that apply to you:


Please check any that you have had:

Important! For the following questions please check any that you experience now or check any that you have experienced in the past:


Mood Swings



Mental Tension


Eye, Ear, Nose and Throat

Frequent Commen Cold

Slow Wound Healing

Chronic Infections


Chronic Fatigue Syndrome

Impaired Vision

Eye Pain Strain

Glasses Contacts


Tearing Dryness

Impaired Hearing

Ear Ringing


Sinus Problems

Nose Bleeds

Frequent Sore Throats

Teeth Grinding

TMJ/Jaw Problems

Hay Fever





Persistent Cough

Shortness of Breath


Frequent Common Colds




Heart Disease

Chest Pain

High Blood Pressure


Heart Murmur


Rheumatic Fever

Varicose Veins

Swelling of ankels






Changes in Appetite


Abdominal Pain


Gall Bladder Disease


Epigastic Pain

Liver Disease


Passing Gas

Hepatitis B or C

Mucous or Blodd

Genito-Urinary Tract

Kidney Disease

Impaired Urination

Painful Urination

Frequent Urination at Night

Frequent Urination

Kidney Stones

Sexually Transmitted Infection

Frequent Urinary Tract Infections

Female Reproductive/Breasts

Irregular Cycles

Difficulty Conceiving

Sexual Difficulties

Heavy Flow

Menopausal Symptoms


Nipple Discharge

Vaginal Discharge

Breast Lumps/Tenderness

Bleeding Between Cycles



Menstrual/Birthing History:

Do you experience painful periods?

Bleeding between cycles?

Are your cycles regular?

Important! For the following questions please check any that you experience now or check any that you have experienced in the past:

Male Reproductive

Sexual Difficulties

Prostate Problems

Testicular Pain/Swelling

Penile Discharge



Neck/Shoulder Pain

Shoulder Pain

Upper back Pain

Upper Limb Pain

Lower Back Pain

Lower Limb Pain

Hip/Groin Pain

Muscle Spasms/Cramps

Joint Pain





Loss of Balance






Diabetes Mellitus

Night Sweats

Feeling Hot or Cold


Skin Rashes





Family History:


Check any conditions that apply to your mother:


Check any conditions that apply to your father:


Check any conditions that apply to your brother(s)


Check any conditions that apply to your sister(s)


Check any conditions that apply to your spouse


Check any conditions that apply to your children


Please indicate typical food intake:

Do you enjoy work?

Have you experienced any major traumas (Physical, Emotional, Mental or Spiritual)?

Notice of Privacy Practices

This notice describes how your medical information may be used and disclosed and how you may gain access to this information. This office is dedicated to providing service with respect and dignity. Protecting your privacy and health care information is fundamental during the course of our relationship.

We are required to tell you how we will be keeping your protected health information confidential. We are asking every patient to sign an acknowledgment form that they received this notice. This notice will remain in effect until it is replaced or amended by changes in the law.

We gather personal information and health information in several ways:
• Information we receive from you.
• Information we receive from other health care providers.
• Information we receive from third party payers.

Your Health Information May Be Used for the Following Purposes
1. You should be aware that during the course of our relationship with you we will likely use and disclose health information about you for treatment, payment, and health care operations.
2. We may use your health information to provide, coordinate and manage health care treatment or service. We may disclose health information about you to health professionals who are involved in taking care of you.
3. We may use information to receive payment from you, an insurance company, or a third party for services we provide.
4. We may use information for certain activities related to business functions of this office.
5. We may use and disclose health information to contact you as a reminder that you have an appointment or we may need to reschedule your appointment.
6. Unless you object, we may disclose your information directly as it relates to such person’s involvement in your health care or payment for such health care.
7. We may use and disclose health information to inform you about recommended possible treatment aftercare options that will benefit you.
8. We may disclose or use minimally necessary health information for other special situations such as public health activities, for averting a serious threat to health or safety, or for workers’ compensation purposes.
9. We will disclose minimally necessary health information about you when required to do so by federal, state, or local laws.

Right to Request Confidential Communications
You may specifically authorize us to protect health information for any purpose or to disclose our health information by submitting the authorization in writing. Such disclosure will be made to any personal representative with whom you choose to share your protected health information.

This office will not use your health information for marketing communications without your written authorization. This office may send you birthday cards, and newsletters, post cards, letters or calls

Patient Rights
Upon written request you have the right to access, review or receive copies of your health care records.
Upon written request you have the right to receive a list of items this office has disclosed about your health care information.
You have the right to request that this office place additional restrictions on disclosure of your Protected Health Information.
You have the right to request that we amend your Protected Health Information. The request must be in writing.
You have the right to receive all notices in writing.
If you have questions, complaints, or want more information, please contact this office. Complaints about your privacy rights or how your privacy is handled at this office can be directed to the office manager by phone or in writing.
If you are not satisfied with how this office handles your complaint you may submit a formal complaint to U.S. Department of Health and Human Services.
DHHS (Office of Civil Rights) 200 Independent Avenue, S.W. Room 509F HHH Building, Washington, D.C. 20201

Informed Consent Form For Acupuncture & Oriental Medicine

All service providers at Wintzer Acupuncture have received advanced degrees in their profession. They hold active licenses in the State of Washington and their individual credentials are available to you upon request.
• Acupuncture, including the use of acupuncture needles or lancets to directly or indirectly stimulate acupuncture points and meridians;
• Use of electrical, mechanical, or magnetic devices to stimulate acupuncture points and meridians;
• Moxibustion;
• Acupressure;
• Cupping;
• Dermal friction technique;
• Infra-red;
• Sonopuncture;
• Laserpuncture;
• Point injection therapy (aquapuncture); and
• Dietary advice and health education based on East Asian medical theory, including the recommendation and sale of herbs, vitamins, minerals, and dietary and nutritional supplements;
• Breathing, relaxation, and East Asian exercise techniques;
• Qi gong;
• East Asian massage and Tui na, which is a method of East Asian bodywork, characterized by the kneading, pressing, rolling, shaking, and stretching of the body and does not include spinal manipulation; and
• Superficial heat and cold therapies.

I recognize the potential risks and benefits of these procedures as described below:
Potential risks: Side effects may include, but are not limited to the following: pain following treatment in insertion area, minor bruising, infection, needle shock, broken needle, temporary discoloration of the skin, aggravation of symptoms existing prior to the treatment, pneumothorax.

Patients with bleeding disorders, pacemakers, seizure disorders, or women who are currently pregnant, please notify the practitioner.
Potential benefits: Drugless relief of presenting symptoms, improved general health, elimination of the presenting problem, reduction of pain and associated symptoms.

With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me regarding cure or improvement of my condition. I hereby release WINTZER ACUPUNCTURE, LLC and providing practitioners from any and all liability, which may occur in connection with the above mentioned procedures, except for failure to perform the procedures with appropriate medical care. I understand that I am free to withdraw this consent and to discontinue participation in these procedures at any time.

Wintzer Acupuncture Financial Policy

Welcome to Wintzer Acupuncture. We want your experience here to be as pleasant as possible. Please ask the staff or your practitioner if you have any questions. To acquaint you with our payment arrangements please review the following and sign in acknowledgement.

1. Self-Pay / No Insurance — Payment is expected at the time services are rendered. We accept cash, check, debit, HSA card and most credit cards.

2. Health Insurance Benefit Summary — As a courtesy, we will verify your insurance benefits when provided with your most current policy information. Your health Insurance is an agreement between you and your insurance company and it is your responsibility to be aware of your benefit plan. We are not responsible for any misinformation that the insurance company may give us. Wintzer Acupuncture will bill your insurance in a timely manner.

3. Health Insurance Payment — Most insurance companies require that you make a copayment, a coinsurance payment, and/or possibly meet a deductible. It is your responsibility to pay these amounts at the time services are rendered unless a specific agreement is made with the office manager. If your insurance company does not pay, the bill is your responsibility and must be paid within 60 days of denial. Any payments after 90 days are subject to the process of collections as initiated by Wintzer Acupuncture. A service charge of $25.00 will be assessed to the account per month after 90 days. We do not write off any balances that have processed towards your deductible - they are your responsibility as outlined by your specific insurance company.

4. Workman’s Compensation — Work related injuries are managed in conjunction with your employer and require you to have an open claim. Employers carry insurance for this type of injury and they must authorize care. It is your responsibility to provide us with a claim number and the contact information for your case manager. In the state of WA, LNI covers Low Back Pain only, up to 10 visits. Private Workman’s Comp has a broader range of coverage and must be approved by the case manager and the parameters of treatment must be specified prior to your initial exam and treatment. If you are working with an attorney and / or involved in a law suit, this information must be provided to our office so that we may appropriately manage your care.

5. Personal Injury Protection Insurance — This is also known as PIP coverage and must be approved through the auto insurance policy responsible for the claim. You will need to provide Wintzer Acupuncture with the insurance company responsible, an open claim number, and your claim manager name and number prior to your initial exam and treatment. If you are working with an attorney and / or involved in a law suit, or have a previous open PIP case or are involved in a previously unsettled claim, this information must be provided to Wintzer Acupuncture so that we may appropriately manage your care. When treating under PIP, your injuries must have been sustained in the incident and your provider will perform a comprehensive initial evaluation and periodic re-evaluations to track progress; this information is sent directly to the company holding the claim. Denial of coverage for services is the financial responsibility of the person seeking care. Wintzer Acupuncture does not reduce the cost of treatment or settle for reduced payment in personal injury cases. you attain a Personal Injury attorney, Wintzer Acupuncture may agree to a lien on a future settlement and accept no payment at the time of service with signed documentation in place. These arrangements need to be made between you, the attorney, and Wintzer Acupuncture. Ultimately you are responsible for any unpaid or denied claims of services rendered. If

6. Medicare — Medicare does not cover acupuncture services performed by a Licensed Acupuncturist and does not allow acupuncturists to be on their In-Network provider list. Senior Advantage plans with a Part C plan MAY have coverage for a set number of visits and Wintzer Acupuncture will call and verify this type of coverage. We are unable to bill Medicare directly. Any non-covered services will be your responsibility.

7. Missed Appointments and Late Cancellations — A fee of $60 will be charges for any missed appointments or late cancellations. Wintzer Acupuncture requires a full 24 hours notice to cancel an appointment. For a Monday appointment, you are expected to cancel by Saturday 5pm. This fee can not be billed to your health insurance, workman’s comp, or auto policy — it is your responsibility. You will be expected to pay this prior to your next date of service unless a plan is made for payment through the office manager.

8. Assignment of Benefits — By signing this form, you are authorizing that payment of medical benefits will be made directly to this office. If your insurance carrier sends payment to you for services rendered in this office, you agree to send or bring those payments to this office upon receipt. If you choose to pay for your treatment out of pocket and submit the receipts to your insurance company for reimbursement, payment will be sent directly to you.

9. NSF — There is a $35 non-sufficient funds fee for any returned checks in addition to what the bank charges for this. You are responsible for this balance within 60 days of notice.

10. Acknowledgment & Understanding — Please notify Wintzer Acupuncture and the Office Manager immediately if there are any circumstances that prevent you from meeting these financial agreements. By signing this form you acknowledge that you are financially responsible and liable for your account at Wintzer Acupuncture and agree to pay for all services rendered in our office. All efforts by Wintzer Acupuncture will be made to reach you regarding your account standing using phone, email, and standard mail services as provided by you in your New Patient Intake paperwork. It is your responsibility to provide the correct & most current information to us and a failure to reach you due to incorrect information does not delay your financial obligations and incurred fees due to non-payment. Any account that is left unpaid for greater than 6 months and including our efforts to contact you will be subject to collections.


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