Kang Acupuncture Herbal Medicine Center

13400 Northup Way, Suite 3 Bellevue, WA 98005 Phone: (425) 401-8885 Fax: (425) 401-8835 Financial Agreement: By signing below, I acknowledge my responsibility for payment for the services received from Kang Acupuncture Herbal Medicine Center, in accordance with their regular rates and terms. My responsibility is not modified by whether any third party pays for all, part, or one of the charges. Specifically, if I have Medicare or Medicaid coverage, I understand that my account becomes delinquent if not paid within 30 days of billing. I also understand that I am responsible to pay reasonable attorneys fees and collection expenses should my account be referred to an attorney or agency for collection. Assignment of Insurance Benefits: I authorize payment to be made directly to Kang Acupuncture by my insurance companies. I understand that I am responsible to pay for charges not covered or paid for by my insurance companies. Assignment of Medicare Benefits: I authorize Kang Acupuncture herbal Medicine Center to release to Federal Government or its designated agent information on this or related medical claims. I permit a copy of this authorization to be used in place of the original and request payment of insurance benefits to be made to the above providers who have accepted assignment. Authorization for Release of Information: I agree that Kang Acupuncture Herbal Medicine Center may disclose information as necessary for the completion of my claim benefits to any person, corporation, or agency responsible for payment of the claims. I understand that my records may contain information regarding the diagnosis/payment of HIV (AIDS virus) other sexually transmitted diseases, drug/alcohol abuse, mental illness or psychiatric treatment. My signature below authorizes the release of such information for payment of claims ONLY. [In compliance with the Omnibus Law]. NOTICE OF INFORMATION PRACTICE: We keep a record of health care services we provide to you. You may ask us to see and copy those records. You may also ask us to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so (exceptions to this care listed above and covered billing practices). You may see you record or get more information about it. To get information about your record, please contact us. [In compliance with the Uniform Health Care Act]. I HAVE READ AND UNDERSTAND THE ABOVE, ALL PERSONAL AND FINANCIAL INFORMATION THAT I HAVE PROVIDED TO INTEGRATED ORIENTAL MEDICINE, IS TRUE AND ACCURATE. Signature: _________________________ (Responsible Party) Patient Relationship to Primary Insured: Self Spouse Child Date: ____________ Time: ___________ Other. If relationship to primary is not Self

Primary Insured Name _________________ DOB _________ Address _____________________________ Insurance Name: _______________________________ ID#_________________ Group#_______________ Co-pay ______________ Deductible _________________ Coverage ___________________________