INFORMED CONSENT: All patients receiving care from a physician must be notified of

potential risks and side effects of treatment. Physical medicine involves exercise to joints and

muscles that may be sensitive because of lack of use, overuse, or injury. The most common

side effect of physical medicine is temporary muscle and joint soreness. Rare side effects may

include fracture in individuals taking corticosteroid medications or individuals with osteoporosis.

The most remote risk involves vascular damage to the vertebral artery in individuals who have

vertebral artery disease. Symptoms of this disease are dizziness, nausea, vertigo, and

unsteadiness when leaning the head back and to one side. If you have ever experienced these

symptoms, please inform your physician.

By signing below, you are consenting to undergo the diagnostic procedures and treatments

recommended by your physician.

MEDICAL RECORDS RELEASE: I authorize the release of information about my treatment to

my other health care providers.

IRREVOCABLE ASSIGNMENT OF BENEFITS: In Considering medical expenses to be incurred, I hereby convey directly to Chicago Chiropractic Group, Ltd., all medical benefits or insurance reimbursement, if any, otherwise payable to me for services rendered from the doctor(s). I understand that I am financially responsible for all charges and outstanding balances regardless of any applicable insurance or benefit payments. I authorize any plan administrator or fiduciary insurer, and my attorney to release all plan documents, insurance policy and/or settlement information upon request in order to claim such medical benefits, reimbursement of any applicable remedies. I authorize the use of this signature on all insurance and/or employee health benefits claim submission.

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT / HIPAA *

For use and/or disclosure of Protected Health Information (PHI) to carry out Treatment, Payment, and Health Operations I, hereby state that by signing this Consent, I acknowledge and agree as follows: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that requires the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge. The HIPAA Security Rule protects a subset of information covered by the Privacy Rule. The Practice’s Privacy Notice has been provided to me prior to my signing this consent. The Privacy Notice includes a complete description of the uses and/or disclosures of my Protected Health Information (PHI) necessary for the Practice to provide treatment to me. I understand it is necessary for the Practice to obtain payment for my treatment and carry out personalized health care operations. I also understand that the Practice reserves the right to change its privacy practices that are described in its Privacy Notice in accordance with the law. The Practice’s Privacy Notice is provided at the time of the patient’s first visit and they have further explained my right to obtain a copy of the Privacy Notice prior to signing this Consent and has encouraged me to read the Notice carefully prior to my signing this Consent. I know it is always available with the staff at the reception desk. I may also request a copy from this office at any time via US Mail. I have read and understood the foregoing notice and all my questions have been answered to my complete satisfaction in a way that I can understand.