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Patient Forms

Forms for your first visit

In order to help you prepare for your first visit to our Berkeley and San Francisco integrative medicine and holistic treatment center, we recommend that you review this section and download the necessary forms and use them in preparation for your visit.

These forms can be filled out online after registration with our integrative medicine and holistic treatment center in Berkeley, or you can print the forms, and fill all the information requested and bring the form to your visit.

Our office aims to provide you excellent medical care and customer service. We have implemented policies that will assist us to achieve our goals that we would like to bring to your attention:

Patient Registration, Policies, Consents, Insurance Forms

Consent to Acupuncture Form

Release of Medical Information Form

Office Policies

New Patients
New patients are advised to arrive to our Berkeley integrative medicine and holistic treatment clinic 15 minutes before their appointment time. We recommend that you have a valid insurance card and current identification at the time of the first visit.

Insurance co-pays
Insurance co-pays are due at the time of service: Patients who do not pay their co-pay are billed a $15.00 service charge in addition to their co-pay. If there is an outstanding balance at the time of appointment, payment will be expected. We accept cash, checks, and all major credit cards for your convenience. There is a $25.00 service charge for a returned check. Insurances are billed as a courtesy and the patient has financial responsibility for payment in full for services rendered.

Insurance coverage
We recommend that patients check with their insurance company whether we are listed under the network and what’s the expected patient’s portion of the payment.

Appointment and Cancellation policy
We recommend arrival 15 minutes prior to the visit. Late arrivals will be seen only upon the discretion of the provider. We request the courtesy of an advanced notification of 24 business hours. If you fail to notify us of your inability to keep your appointment, a “no-show” for your appointment time will be noted in your chart. After two consecutive no-shows, you may be considered for discharge from the practice. All patients who fail to present for their visits or cancel within 24 hours of their appointment will be subject for a fee. The fee will be waived if they reschedule within 24 hours after the missed visit. The charge is $50.00 for the first visit and $25.00 for a follow-up visit.

Prescription refills
New prescriptions and prescription changes are available to you during your visit. Refill requests should be made to your pharmacy. Please do not wait until you are out of medication to request a refill and allow 72 hours for prescription refills.

Lab copies
Most of the time, your labs will be available to be seen through the patient portal online. Paper copies of your labs can be requested during your visit as well.

Medical records
If another practitioner is requesting your records, they can be sent electronically, faxed, or mailed at no charge to you after you sign a medical release. Otherwise, to obtain a copy of medical records a fee of 10 cents per page and $6.00 per 15 minutes of processing fee is paid on request, and may take up to two weeks. The records can be picked up at the office. Upon request they may be mailed Certified/Return Receipt for an additional cost of the mailing fee.

Online Communication
As a courtesy to our patients, we respond to your requests online through the patient portal. We recommend that the online communication be brief and limited to simple questions and answers. Please allow 24 – 48 hours for a response from our office. For urgent matters, we recommend that you call our office.

E-visits are available to established patients who have previously received care from the practice for a cost of $70 per visit and can be requested and conducted through the patient portal.

Phone visits
Communication with the physician through the portal is provided as a courtesy to our patients. Follow up visits on the phone upon the discretion of the provider.

After-hour phone calls
We are happy to answer the phone during our regular business hours, which is Monday to Friday, 8:30 am till 5:30 pm and we are closed for lunch between 12:00 pm and 1:00 pm. If you call our office after 5:30 pm or over the weekend, we advise that you leave a message and we will respond to you the next business day. If you have a matter that requires urgent medical attention, we advise that you visit the nearest Emergency Room.

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