While the law requires us to give you this disclosure, please understand that we have, and always will, respect the privacy of your health information. There are several circumstances in which we may have to use or disclose your health information.
We have a more complete notice that provides a detailed description of how your health information may be used or disclosed. You have the right to review that notice before you sign this consent form. (164.520)Your Right to Limit Uses or Disclosures: You have the right to request that we do not disclose your health information to certain individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions.Your Right to Revoke Your Authorization: You may revoke your consent 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 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.I authorize you to use and disclose my information in the manner described above, to my primary care physician, and to:Name: blanks* Relationship to patient: blank* I have read your consent policy and agree to its terms.Initials: Signature*
Informed Consent to Chiropractic Treatment
The nature of chiropractic treatment: The doctor will use his/her hands or a mechanical device to adjust/manipulate your joints. You may hear a “pop” or “click” like when a knuckle is “cracked”, and you may feel movement in the joint. Various ancillary procedures, such as hot or cold packs, electric stimulation, therapeutic ultrasound, and traction as well as exercise instruction and other modalities may also be used. There are inherent risks in all treatment derived by any health care provider ranging from taking a single aspirin to a complicated brain surgery. Chiropractic care is no exception. Although we take every precaution, there is a very low incidence of complication associated with chiropractic services, and anyone undergoing adjustment or manipulative therapy procedures should know the possible hazards and complications which may be encountered. These include, but are not limited to fractures, disc injuries, stroke, dislocations, sprains, and those which related to physical aberrations unknown or reasonably undetectable by the doctor.I understand that the practice of neither chiropractic nor medicine is an exact science and that my care may involve the making of judgments based upon the facts known to the doctor at the time; that it is not reasonable to expect the doctor to be able to anticipate or explain all risks and complications; that an undesirable result does not necessarily indicated an error in judgement; that no guarantee as to results has been made to nor relied upon by me, and I wish to rely on the doctor to exercise judgement during the course of the procedure which he/she feels at the time, based upon the facts then known, is in my best interests.Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility and include chronic pain cycles. It is quite probably the delay of treatment will complicate the condition, make further rehabilitation more difficult or impossible. Concerns or questions: please ask your doctor to explain any concerns about treatment you may have.I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures on me or on my dependent/charge, by the licensed Doctor of Chiropractic (D.C.) employed or engaged in practice at East West Chiropractic.I have read the above consent to chiropractic care. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment.Initials: Signature*
Emails and Appointment Reminders
We may need to use your name, address, phone number and your clinical records to contact you with appointment reminders (text and email), information about treatment alternatives, or other health related information that may be of interest to you. This information may also be used for the purpose of sending birthday/holiday cards and messages, occasional newsletters, etc. If this contact is made by phone and you do not answer, a message will be left on your answering machine. By signing this, you are giving us authorization to contact you with these reminders and information. Information that we use or disclose based on the authorization you are giving us may be subject to re-disclosure by anyone who as access to the reminder or other information and may no longer be protected by the federal privacy rules. You have the right to refuse this authorization. If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care. You may inspect or copy the information that we use to contact you to provide appointment reminders, information about treatment alternatives, and other health related information or marketing at any time. Telephone calls, text messages, and emails may be monitored for quality control.I authorize you to use and disclose my health information in the manner described above.Initials: Signature
Our Payment Policy
I understand that all services are to be paid in full at the time of service. I hereby authorize the doctor to release all information necessary to secure the payment benefits. I clearly understand that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional service rendered to me will be immediately due and payable. I authorize the use of signature on my insurance submissions.Name: First Name Last Name Signature: Signature Date: Date