Homer Clinic:

NOTE:  All required forms, including any insurance information, needs to be brought to your first appointment, OR we will need to reschedule your appointment for a later date if you forget to bring your paperwork to the appointment with you. There probably will not be enough time for your appointment if you arrive at your appointment at the scheduled time without your paperwork in hand, filled out, so put it where you will not forget to bring it with you, like in your car.  You may submit electronically to valerie@triggerpointrelief.com.  If you have to be rescheduled, you may not be able to get in for another week or two.

Patient Information
This will take about 5-10 minutes to complete.

Patient Care Financial Agreement
This will take about 5 minutes to read and complete.  Please call in advance for a financial consultation to get estimated charges so you know what to expect.  For insurance information, go to InsuranceInformation.html.  If you do not have insurance and want to request a financial need discount, please fill out the form below.

Medical History Form
This will take about 30 minutes to complete, depending on the number of health conditions you have. The more completely you fill out the form, the better I can diagnose and treat you, and the more value you will get from your appointments.

HIPPA Notice of Patient Privacy Policies
This will take about 5 minutes to read.

HIPPA Consent Form
This will take about 5 minutes to read and complete. I legally have to have this consent form per U.S. HIPPA statutes.

Financial Need Worksheet  If you do not have insurance and want to request a financial need discount, please fill out this form to see if you qualify for a discount.

For Personal Injury Cases (i.e. auto accidents):
Assignment & Instruction for Direct Payment
This will take about 5 minutes to read and complete.  This instructs the insurance company to pay Alaskan Acupuncture directly.

Power of Attorney to Endorse Insurance Checks
This will take about 5 minutes to read and complete.  This allows Alaskan Acupuncture Inc. to deposit any insurance checks that are either made out to the patient only, or checks that are issued jointly to Alaskan Acupuncture Inc. and the patient.

Notice of Practitioner's Lien
This will take about 5 minutes to read and complete.  If you are represented by an attorney, this instructs your attorney to pay your treatment bills if the payment is made to him/her instead of this office.

Rescission of Attorney Assignment of Benefits
This will take about 5 minutes to read and complete.  This directs the insurance company to pay Alaskan Acupuncture Inc. directly for your treatment bills, rather than your attorney.