Dr. Andrew Jahner DC Dr. Nick Barney DC
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Pertaining to HIPPA (Health Insurance Portability Act) The Patient
Consent for below complies with
Federal Law
Appointment Calls, Open Room Adjusting & Health Care Information
Dr. Barney, Dr. Jahner and the staff of Optimal Chiropractic may need to use your name, address, phone number and your clinical records to contact you with appointment reminders, information about treatment alternative or other health related information that may be of interest to you. If this contact is made by phone and you are not home, a message will be left on your answering machine or with a family member. By signing this form you are giving us authorization to contact you with these reminders and information.
You can restrict the individuals or organizations to which your health care information is released or you may revoke your authorizations to us at any time, however, your revocation must be in writing and mailed to us at our office address. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke the authorization. In addition, if you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.
Information that we use or disclose, based on the authorization you give us, may be subject to re-disclosure by anyonewho has access to the reminder or other information and may no longer be protected by the federal privacy rules.
You have the right to refuse to give us this authorization. If you do not give us authorization, if will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.
We offer spinal adjustments in an open room style. Occasionally comments about your symptoms, improvements or lack there of may be discussed at your office visit.
We might use your name, photo, or testimonial during the normal course of business. It is your responsibility to inform the Optimal Chiropractic staff if you do not wish to partake.
You may inspect or copy the information that we use to contact you to provide appointment reminders, information about treatment alternatives of health related information at any time. (#164.524)
This notice is effective as of November 9, 2015. This authorization will expire seven years after the date in which you last received services from us.
I authorize you to use or disclose my health information in the manner described above. I also understand that I may receive a copy of this form when needed.