I hereby request and consent to the performance of Chiropractic Adjustments, massage therapy, and/ or other chiropractic procedures including various modes of physical therapy, and if necessary, diagnostic x-rays on me (or on the patient named below, for whom I am legally responsible. I further understand that such services may be performed by Dr. Jessica Diamond, Doctor of Chiropractic and/or any licensed Doctor of Chiropractic who may treat me now or in the future at this office. X-rays are not taken on pregnant women in this office. I have had an opportunity to discuss with Dr. Jessica Diamond and/or with other office or clinic personnel the nature and purpose of Chiropractic Adjustments and/or other procedures. I understand that results are not guaranteed. I understand and am informed that, as in the practice of medicine and all healthcare, the practice of Chiropractic and other healthcare services carries some risks to treatment, including, but not limited to: fractures, disc injuries, strokes (CVA), dislocations, and sprains. I do not expect the Doctor of Chiropractic to be able to anticipate and explain all risks and complications. Further, I wish to rely on the doctor of Chiropractic or another provider to exercise judgment to determine the course of care, which is in my best interests at the time, based on the facts then known. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its contents, and by signing below, I agree to the treatment recommended by my Doctor of Chiropractic. I intend this consent form to cover the entire course of treatment for my present condition(s) and for any condition(s) for which I seek treatment at this facility. To avert a serious threat to health or safety, we will disclose your health information when necessary to prevent a serious threat to the health and safety of you, the public, or another person. Disclosure, however, will be made only to someone who may be able to help provide treatment. Business Associates. We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than that as specified in our contract. Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in the procurement, banking, or transportation of organs, eyes, or tissues to facilitate organ, eye, or tissue donation and transplantation. Military and Veterans. If you are a member of the armed forces, we may use or release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military. Workers Compensation. We may release Health Information for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illnesses. Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosure to prevent or control disease, injury, or disability; reporting child abuse or neglect; reporting reactions to medications or problems with products; notifying people of recalls of products they may be using; informing a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and report to the appropriate government authority if we believe a patient has been a victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required by law. Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by bylaw. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or a court administrator order. We also may disclose Health Information in response to a subpoena, discovery request, or another lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is: 1) in response to a court order, subpoena, warrant, summons, or similar process; 2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; 3) about the victim of a crime even if, under certain circumstances, we are unable to obtain the person’s agreement; 4) about a death we believe may be the result of criminal conduct; 5) about criminal conduct on our premises; and, 6) in an emergency to report a crime to the location of the crime or victims, or the identity, description or location of the person who committed the crime. Coroners, Medical Examiners, Funeral Directors. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information to funeral directors as necessary for their duties. National Security, Protective Services, and Intelligence Activities. We may release Health Information to authorized federal officials so that they may provide protection to the President, other authorized persons, or foreign heads of state, or conduct special investigations. Inmates or Individuals in Custody. If you are an inmate of a correctional institution or other custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be made if necessary: 1) for the institution to provide you with health care; 2) to protect your health and safety or the health and safety of others; or, 3) for the safety and security of the correctional institution. Your right you have the following rights regarding the Health Information we have about you. Right to Inspect and Copy. You have the right to inspect and copy Health Information that we may use to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this information, you must make your request in writing to our Privacy Officer. Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment during the time the information is kept by or for our office. To request an amendment, you must make your request, in writing, to our Privacy Officer. Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of health information for purposes other than treatment, payment, and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to our Privacy Officer. Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have a right to request a limit on the health information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you can ask that we not share information about your particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to our Privacy Officer. We are not required to agree with your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.Right to Request Confidential Communication. You have the right to request that we communicate with you about your medical matters in a certain way or at a certain location. For example, you can ask that we contact you only by mail or at work. To request confidential communications, you must make your request, in writing, to our Privacy Officer. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests. Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you agree to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice by contacting our office. Changes to this notice we reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a current copy of our notice at our office. The notice will contain the effective date in the bottom, right corner of each page. complaints you believe your privacy has been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact our Privacy Officer. All complaints must be made in writing. You will not be penalized for filing a complaint. By affixing my signature below, I acknowledge receipt of this notice, and my understanding of, and agreement with, its terms.