Forms

Home » Forms

New Patients: Please complete the new patient form below for the type of provider you are scheduled with (including the HIPAA/Financial Responsibility form) and bring them with you to your first appointment. If you are not able to get them finished ahead of time please plan to arrive 30 minutes early. We know the forms are lengthy but it allows us to get the information we need to treat you and focus on your current concerns at the initial appointment.  If you have any questions, please give us a call!

We strongly encourage you to check your insurance benefits prior to your appointment if you would like us to bill your insurance. We have provided a form below to use when calling your insurance company.

On the day of your appointment please bring with you your photo ID as well as your insurance card if we are billing your insurance.

Other Forms

TitleVersionDate modifiedDownload
Medical Records Release 06-03-2019 DownloadPreview
Check Medical Benefits 06-03-2019 DownloadPreview

Cancelation Policy:  Please be aware that we ask patients to give us 48-hour notice if they need to reschedule or cancel an appointment.  Late cancellations or missed appointments will incur a fee, as we are unable to reschedule the appointment with another patient without sufficient notice.

Parking & Accessibility:

Our NW location is located just west of the intersection of NW 23rd on NW Flanders (between 23rd & 24th Ave.). Parking is available in the main and lower lot; please do not park below the building in the covered area. There is also metered street parking throughout the neighborhood. Wheelchair access for the first floor is located through the main level parking lot. Please come a few minutes early and enjoy a cup of tea before your appointment.

Our NE location is located at the corner of NE 31st and NE Sandy Blvd in the Bindery Building. Street parking is available along NE 31st both North and South of Sandy Blvd. Wheelchair access is through the door on NE Sandy Blvd and up the elevator. The clinic is located on the second floor, just look for signs pointing towards Suite 231.

Insurance: Our clinic accepts most insurance plans.  As a courtesy, Kwan-Yin Healing Arts Center will bill your insurance on your behalf. Insurance information given to Kwan-Yin Healing Arts Center by your insurance company is not a guarantee of payment. This includes information provided about covered treatments, copays, coinsurance, deductibles, and pre-authorizations.

It is your responsibility to read your own policy, know your coverage, and review the explanation of benefits statements regarding payments. Please remember your insurance policy is a contract between you and the insurance company, we cannot guarantee payment of your claims It is ultimately your responsibility to pay for any balance not paid or covered by insurance. Any charges that are not covered by the given insurance company will be billed to you.

Below is a list of some procedures codes that may not be covered by your insurance, but may be necessary during the normal course of an examination to diagnose, evaluate and give you the care you need.

97140: Manual Therapy (Billed out for Maya Abdominal Therapy)
97014: Electric Stimulation
97035: Therapeutic Ultrasound
97810: Initial 15 minutes Acupuncture
97811: Additional 15 minutes Acupuncture
99354, 99355: Prolonged Services
99358: Additional Research Outside of the Office Visit

A decline of these treatments must be made acknowledged in writing prior to the services being performed.

Scroll to Top