If you are a new patient, Dr. Levy asks that you print out and complete one or more of the following forms, which can be accessed through the following four links. The first link is the Medical Record Release Form, which will enable us to get past health history and information for completion of your care. The second link connects to the Acupuncture Acceptance form; this form asks that you acknowledge that acupuncture and herbal therapies may not be a covered benefit of your insurance company, and that you are responsible for any charges that are incurred from such treatments. The third link opens the Patient History Form, a two-page form that asks for information about your medical history, family history, and so on. The final link, the Patient Package Form, opens a 3-page form requesting information such as patient registration information, employer information, and family tree data. This form also provides financial policy and procedure information.

The following forms are in PDF format. Right click to download to your computer then print from Acrobat Reader. Acrobat Reader is available for free from Adobe.com.

Authorization to Use and Disclose Protected Health Information

Acupuncture Acceptance

Patient History Form

Patient Package Form