Secure Intake Form- Meeting Point Acupuncture

Secure Intake Form- Meeting Point Acupuncture

Acupuncture Clinic Intake Form Colorado Form Preview
  • Meeting Point Community Acupuncture LLC

    Affordable Healthcare in Denver and Golden Colorado
  • Welcome Letter

    Welcome to our Community!

    Please take a minute to read this introduction to our clinic and to our community. We are delighted that you are interested in joining us!

    What is different about Meeting Point Acupuncture Clinic?

    We treat in a community setting

    Most US acupuncturists treat patients on tables in individual cubicles. This is not traditional in Asia, where acupuncture usually occurs in a community setting. In our clinic we primarily use recliners, clustered in groups in a large, quiet, soothing space. Treating patients in a community setting has many benefits: it’s easy for friends and family members to come in for treatment together; many patients find it comforting; and a collective energetic field becomes established which actually makes individual treatments more powerful. In some styles of acupuncture, the needles are removed after only a few minutes or after a half hour at most. The style of acupuncture we practice at MPA allows patients to keep their needles in as long as they want, and the “right” amount of time varies from patient to patient. Most people learn after a few treatments when they feel “done”; this can take from twenty minutes to a couple of hours! Many people fall asleep, and wake feeling refreshed.

    We have a sliding scale

    Most US acupuncturists also see only one patient per hour and charge $65 to $175 per treatment. They tend to spend a long time talking with each patient, going over medical records, asking many questions. We don’t. The only way that we at MPA can make acupuncture affordable and still make a living ourselves is to streamline our treatments and see multiple patients in an hour, so we have returned to the traditional approach; instead of asking you lots of questions, we rely on focused questions along with pulse and tongue diagnosis to decide how to treat you. This is exactly how acupuncture is practiced traditionally in Asia -- many patients per hour and very little talking.

    Because we have a sliding scale, we cannot do insurance billing (that’s the insurance companies’ rule). If you have insurance that covers acupuncture, we’ll be happy to give you a payment receipt, and you can submit it; that’s OK with the insurance companies.

    Our Commitment to You

    We want to make it possible for you to receive acupuncture regularly enough and long enough to get better and stay better. We want our community to be welcoming to all different kinds of people. We want to give you the tools to take care of your own health. We will provide a safe environment with skilled practitioners.

    What We Need From You


    MPA does not provide primary care medicine. Acupuncture is a wonderful complement to Western medicine, but it is not a substitute for it. If you think you have a problem that is not “garden variety” (meaning, you are worried that you might have a serious infection, a malignant growth, or an injury that won’t heal), or if you want someone knowledgeable to go over the details of your medical history with you, you need to see a primary care physician (ND, MD, or DO). You cannot expect us to diagnose and treat something really serious. We can provide complimentary care for conditions which require a physician’s attention -- for instance, we often treat patients for the side effects of chemotherapy. But we need you to take responsibility for your own health.

    MPA does not receive grants, state or federal money, or insurance reimbursement. MPA exists because patients pay for their treatments – it a sustainable community business model.


    The community setting requires some flexibility from you. For instance, many patients have a favorite recliner. When we are busy, someone may be sitting in yours. Similarly, we have a few patients who snore. Other patients who dislike snoring bring earplugs to their treatments. We are grateful for this! Some of our patients even bring favorite pillows or blankets from home with them, because they prefer theirs to ours. That’s fine with us. Basically, we need you to participate in making yourself comfortable in the community room before we arrive to treat you.

    In terms of how long you want to stay -- tell the practitioner if you need to be somewhere at a certain time! We’ll make sure you’re out on time. In general, if you feel done, open your eyes and give us a meaningful look -- if your eyes are closed, we think you’re asleep and we won’t wake you up.


    The soothing atmosphere in our clinic exists because all of our patients create it by relaxing together. We appreciate everyone’s presence! This kind of collective stillness is a rare and precious thing in our rushed and busy society. Maintaining this reservoir of calm requires that no one talk very much in the clinic space. If you would like to speak to a practitioner one-on-one at any length, please let us know. If you want to have a substantial conversation, we will probably need to schedule that separately and might need to do it by phone.

    Unfortunately, we can’t explain what every point does, or how acupuncture works, while we are treating you -- these are very large topics! This is why our Resource Center exists. If you have questions, we’ll happily give you plenty to read!

    Part of our success is that our patients learn the “routine” and take on a lot of responsibility for the appointments. Re-scheduling and making payment happens at the front desk BEFORE each treatment (except for the Initial treatment) so you can relax and enjoy treatment. Please turn off your cell phone and bring any personal belongings that you would feel better having with you and put them next to your chair


    Acupuncture is a PROCESS. It is very rare for any acupuncturist to be able to resolve a problem with one treatment. In China, a typical treatment protocol for a chronic condition could be acupuncture every other day for three months! Most of our patients don’t need that much acupuncture, but virtually every patient requires a course of treatment, rather than a single treatment, in order to get what they want from acupuncture.

    One big reason that we are able to keep our prices so low is because of the extraordinary amount of marketing our patients do on our behalf -- we don’t have to advertise. We cannot express how grateful we are for this. Our patients are such effective marketers because they have first-hand experience of how well acupuncture works. All of our satisfied patients basically made a commitment to a course of treatment.

    On your first visit, your acupuncturist will suggest a course of treatment, which can be anything from “we’d like to see you once a week for six weeks” to “we’d really like to see you every day for the next four days”. This suggestion is based on our experience with treating different kinds of conditions. If you don’t come in often enough or long enough, acupuncture probably won’t work for you. The purpose of our sliding scale is to help you make that commitment. If you have questions about how long it will take to see results, please ask us, or if you think you need to adjust your treatment plan, please let us know. We need you to commit to the process of treatment in order to get good results.

    And, last, but not least….enjoy the space. We hope that Meeting Point Acupuncture can be an important part of your community.

    Thank you, Meeting Point Acupuncture Staff

  • Patient Intake Form

    We value your privacy, this form is HIPAA compliant
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  • Patient Information

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  • Emergency Contact Information

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  • Main Problem(s)

    Primary reason(s) for today's visit
  • Medical History

    Please include the month and year when the event occurred and/or when the diagnosis was established
  • Please indicate if you or a blood relative have had the following:
  • Lifestyle Information

  • Daily Dietary Intake

    (please describe in as much detail an ordinary day of dietary intake for yourself)
  • Symptoms Survey

    Please check if you have or have had (in the last 3 months) any of the following conditions:

  • Female Disorders & Symptoms

    (if not applicable skip to next section)

  • Male Disorders & Symptoms

    (if not applicable skip to next section)

  • Mandatory Disclosure & Consent to Treat

    Please read and then sign & date below:

    24 hour notice is required for change of appointment or cancellation. If you are unable to give 24 hour notice, we will do our best to fill your space if we are unable to do so you will be charged $30 fee for that appointment.

    Meeting Point Acupuncture, LLC
    570 S. Broadway, Denver, CO 80209
    1224 Washington Ave, Ste 40, Golden, CO 80401

    Practitioner Education, Certification, and Experience

    Jessica Hardy, Dipl. Ac., L.Ac.-Master of Science in Traditional Chinese Medicine from Colorado School of Traditional Chinese Medicine in 2003. NCCAOM Diplomate in Acupuncture issued in 2003. Colorado Licensed Acupuncturist (#971).

    Jamie Holland, Dipl O.M., L.Ac., ACN, ABT.-Master of Science in Acupuncture & Oriental Medicine from AOMA Graduate School of Integrative Medicine in 2013, NCCAOM Diplomate in Oriental Medicine issued in 2013. CO Licensed Acupuncturist (#1937). Applied Clinical Nutritionist (2013, TX Chiropractic College), Asian Bodywork Therapist (2012, American Organization of Bodywork Therapies of Asia)

    Robert Gottko, Dipl.Ac., L.Ac.-Master of Science in Acupuncture from Pacific College of Oriental Medicine in 2011. NCCAOM Diplomate in Acupuncture issued in 2011. Colorado Licensed Acupuncturist (#1812).

    Nathan Kizer, Dipl.Ac, L.Ac.-Master of Science in Acupuncture from Jung Tao School of Classical Chinese Medicine in 2013, NCCAOM Diplomate in Acupuncture issued in 2013. Colorado Licensed Acupuncturist (#2086).

    Alicia Kelley, Dipl.O.M., L.Ac.-Master of Science in Oriental Medicine from Southwest Acupuncture College in 2016. NCCAOM Diplomate in Acupuncture issued in 2016. Colorado Licensed Acupuncturist (#2244).

    Kyle Guarneros, Dipl. O.M., L.Ac.-Masters of Science from Southwest Acupuncture College in 2017, NCCAOM Diplomate of Oriental Medicine. Colorado Licensed Acupuncturist (#2316)

    No license, certificate or registration has ever been revoked or suspended.

    Clinic Fee Schedule (due at time of service)

    Community Room: Sliding scale of $20-$40 with an additional $15 for initial intake

    Herbal Consultation: Sliding Scale of $20-$40 plus cost of herbs

    Tuina Bodywork: $55/hr, $70/1.5hrs

    Nutritional Consult: Initial Consult -$55, Follow up -$40, plus cost of supplements and/or herbs

    Insurance: We do not bill insurance. Upon request, we will provide you with a receipt for your insurance company.

    This disclosure statement is in compliance with the State of Colorado, Department of Regulatory Agencies, Colorado Statute Title 12 Article 29.5. All rules and regulations set forth by the Department of Health are strictly adhered to, including proper cleaning, sterilization, and sanitation of equipment and office. The practice of acupuncture is regulated by the Director of Registrations, Colorado Department of Regulatory Agencies.

    If you have any comments, questions, or complaints, contact the Acupuncturists Registrations Office:

    Director of Professions and Occupations
    Acupuncture Licensure
    1560 Broadway, Suite 1350
    Denver, CO 80202
    (303) 894- 7800

    I hereby request and consent to the performance of acupuncture procedures by my acupuncturist(s), Jessica Hardy, Jamie Holland, Robert Gottko, Nathan Kizer, Michael Daborwski and Alicia Kelley. I have been informed that acupuncture is a safe method of treatment but that it may have side effects including discomfort, pain, dizziness, bruising, or numbness at site of procedure. Unusual and rare risks of acupuncture include nerve damage, organ puncture including lung puncture, infection, and spontaneous miscarriage. Other side effects and risks may occur. If I suspect that I am pregnant, I will immediately inform the acupuncturist.

    I have discussed the nature and purpose of my treatment with the acupuncturist(s) named above. I understand that there are no guarantees regarding cure of improvement of my condition. I understand that there may be limitations to the care provided and that in my best interest I may be referred to another acupuncture practitioner or other healthcare provider who may be more qualified to treat me outside of these facilities. I do not expect the acupuncturist to anticipate and explain all possible risks and complications, and I permit the acupuncturist to determine and/or alter the course of treatment which the acupuncturist judges to be in my best interests based upon the facts then known. I understand that I have the choice to accept or reject treatment at any time. I have read or have had read to me the above consent. I have also had the opportunity to ask questions about its content, and by signing below, I agree to all terms and conditions stipulated by this document. I intend this form to cover the entire course of treatment for my condition and for any future condition(s) for which I seek treatment.

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  • HIPAA Policy and Acknowledgment (Privacy Practices)

    Please read, and then sign & date below:

    This notice contains important information about our clinic privacy practices. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

    What is this notice?

    Meeting Point Acupuncture must collect, maintain and use Non-public Personal Information (NPI) on patients, before providing them with our service. We consider this information private and confidential and have policies and procedures in place to protect the information against unlawful use and disclosure. This notice describes what types of information we collect, explains when and to whom we may disclose it, and provides you with additional important information as to our legal duties and privacy practices. It also describes you rights to access and control your NPI. Meeting Point Acupuncture is required to abide by the terms of this notice. However, we may modify the terms of this notice at any time, and the new notice will be effective for all NPI in our possession at the time of the change, and any treated received thereafter. The information collected by our office is used, maintained, and protected by federal law, The Health Insurance Portability and Accountability Act (HIPAA). Our office does not disclose NPI to anyone, except with your authorization, or otherwise, as permitted by the above law. If you believe your privacy rights under the HIPAA act have been violated, you can submit a written complaint to this clinic’s Privacy Office, address below. You may also complain to the Secretary for Health and Human Services if you believe your privacy rights have been violated. There will be no retaliation for filing a complaint.

    What is “non-public personal information” (NPI)

    Non-public personal information (NPI) is information that identifies you as an individual and relates to your participation in treatment, your physical or mental health/condition, the provision of treatment or healthcare to you or payment to the institute for the provision of services provided to you.

    How does this clinic protect patients’ NPI

    • We restrict access to NPI to members of our workforce (staff and trainees) who need to provide care or services to you or are engaged in our clinic’s operations.
    • We maintain physical and procedural safeguards to protect your information against unauthorized access and use.
    • We have assigned a Privacy Officer who has overall responsibility for developing privacy procedures, educating our workforce, and overseeing the implementation and enforcement of policies and procedures to safeguard your health information against inappropriate access, use and disclosure, consistent with applicable law. You may contact: Meeting Point Acupuncture, Office Manager, 570 South Broadway Denver, CO 80209

    How does this clinic use NPI, and for what purposes

    Treatment: We may use or disclose your NPI in order to provide you with services and treatment you require or request. We are also permitted to disclose this information within and among our workforce in order to accomplish the same process. However, we are required to limit such uses or disclosures to the minimal amount that is required to provide those services or to complete these activities. Some example of service related disclosure include: the provision, coordination or management of health care and related services by health care providers; consultation between health care providers relating to a patient; referral of a patient for health care from one health care provider to another.

    Payment: We may use and disclose NPI so that treatment and services you receive may be billed to and payment collected from you or a third party. For example, we may complete and submit to your healthcare plan or insurance company a description of treatment provided to you. We also may use and disclose your NPI to obtain payment from other third parties that may be responsible for the costs, such as family members.

    Health Care Operations: We may also use and disclose NPI to perform health care operations. This is necessary to make sure that all of our patients receive quality care. For example, we may use and disclose NPI for the following: to review our treatment and services and to evaluate the performance of our staff and trainees; to develop clinical guidelines; to inform patients of treatment alternatives; for case management and care coordination as well as general administrative activities such as customer service.

    What uses and disclosures do not require your authorization

    Below are some examples of circumstances under which we are permitted by law to use or disclose your NPI without your authorization.

    Business Associates: We may contract with outside individuals and organizations that perform business services for us, such as billing, management consultants, accreditation organizations, quality assurance reviewers, accountants or attorneys. In certain circumstances, we may need to share your information with a business associated so it can perform a service on our behalf. Our clinic will limit the disclosure of information to a business associate to the amount of information that is the minimum necessary for the business associate to perform services for us. In addition, we will have a written contract in place with the business associate requiring it to protect the privacy of your information.

    As required by Law: We will disclose NPI when required by federal, state or local law. We may disclose NPI to public health authorities that are authorized by law to collect information for the purpose of:

    • Reporting child abuse or neglect
    • Notifying appropriate government agencies and authorities regarding the potential abuse or neglect of an adult patient (including domestic violence)
    • Preventing or controlling disease, injury or disability
    • Notifying a person regarding the potential risk for spreading or contracting a disease or condition
    • Reporting reactions to drugs or problems with products or devices
    • Notifying individuals if a product or device we may be using has been recalled
    • Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance CONTINUED

    Health Care Oversight Activities: We may disclose NPI to a health oversight agency for activities authorized by law. Oversight activities can include some of the following: investigations, inspections, audits, surveys, licensure and disciplinary actions; civil administrative and criminal procedures or actions; or other activities necessary for the government to monitor compliance with civil rights laws and the health care system in general.

    Lawsuits and Disputes: We may use and disclose NPI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your NPI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain a court order protecting the information the party has requested.

    Law Enforcement: We may disclose NPI if asked to do so by a law enforcement official as part of law enforcement activities, in investigations of criminal conduct at our institute or of victims of crime, in emergency situations to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator); or when required to do so by law.

    Serious Threats to Health or Safety: We may use and disclose your NPI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

    Military: We may use and disclose NPI if you are a member of United States or foreign military forces (including veterans) and if required by the appropriate military command authorities.

    Protective Services for the President, National Security and Intelligence Activities: We may use and disclose NPI to federal officials for intelligence and national security activities authorized by law. We also may disclose your NPI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

    Worker’s Compensation: We may release NPI for worker’s compensation or similar programs.

    Your rights governing the information we collect, use and maintain

    The Right to Inspect and Copy: You have the right to inspect and obtain a copy of your NPI that we maintain and have in our possession, including treatment records and billing records. If you request copies, we will charge you a fee for the costs of copying, mailing, labor and supplies associated with you request. To inspect and copy your NPI, you must submit your request in writing to Meeting Point Acupuncture 570 S. Broadway St. Denver, CO 80209. By law you may inspect and obtain copies of your NPI, contained in your designated records, except for the following:

    • Psychotherapy notes
    • Information complied in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding
    • Health information maintained by us to the extent to which the provision of access to you would be prohibited by law.

    We will reasonably attempt to accommodate any request for NPI excluding the information as to which we have a ground to deny access. Upon denial of a request we will provide you with a written denial specifying the legal basis for denial, a statement of your rights, and a description of haw you may file a complaint with us.

    The Right to Amend or Correct NPI: If you feel that any NPI we have about you is not correct or incomplete, you may ask us to correct or amend the information. We keep your information for seven (7) years. You have the right to request an amendment within this time. To request an amendment, your request and the reason that supports the request must be made in writing to Meeting Point Acupuncture 570 S. Broadway St. Denver, CO 80209. Our office reserves the right to deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

    • Was not created by us
    • Is not part of the medical information kept by us
    • Is not part of the information which you would be permitted to inspect and copy
    • Is accurate and complete

    The Right to an Accounting or Disclosures: An accounting of disclosures is a list of the disclosures we have made, if any, of your NPI. You have the right to request an accounting of disclosures made by us. This right applies to disclosures for purposes other than those made to carry out treatment, payment and health care operations as described in this notice. It also excludes communications of NPI made to you or disclosures authorized by you. Your request must be made in writing and state a time period that cannot be longer than six (6) years. We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

    The Right to Receive Communications of NPI by Alternative Means or at Alternative Locations: You have the right to request that we communicate with you about your treatment and related issues in a particular manner or at a certain location. For example, you may ask that we contact you at work rather than at home. We will accommodate all reasonable requests made in writing.

    The Right to Request Restrictions: You have the right to request a restriction or limitation on the NPI we use or disclose about you for treatment, payment or health care operations as described in this notice. You also have the right to request a limit on the treatment information we disclose about you to someone who is involved in your care or the payment for your care (like a family member or friend). Our office is not required to agree to your request, however, if we do agree, we will comply with your request until we receive notice from you that you no longer want the restriction to apply. Any request for a restriction on our use and disclosure of your NPI must be made in writing to the address below. Your request must describe in a clear and concise manner: (a) the information you wish restricted; (b) whether you are requesting to limit our use, disclosure or both; and (c) to whom you want the limits to apply.

    The Right to Provide an Authorization for Other Uses and Disclosures: We will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your NPI may be revoked at any time in writing to the address below. After you revoke your authorization, we will no longer use or disclose your NPI for the purposed described in the authorization, except under the following circumstance: We have taken action in reliance upon your authorization before we received your written revocation.

    The Right to Obtain a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice of privacy practices at any time by contacting our office:

    Meeting Point Acupuncture: 570 S. Broadway, Denver, CO 80209

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