I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate. I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered. This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition, we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances. If you would like a more detailed explanation, one will be provided to you. In addition, you will find we have placed several copies in report folders labeled ‘HIPAA’ on tables in the reception. Once you have read this notice, please sign the last page.

1. Treatment purposes- discussion with other health care providers involved in your care

2. Inadvertent disclosures- open treating area mean open discussion. If you need to speak privately to

the doctor, please let our staff know so we can place you in a private consultation room.

3. For payment purposes - to obtain payment from your insurance company or any other collateral

source.

4. For workers’ compensation purposes- to process a claim or aid in investigation

5. Emergency- in the event of a medical emergency we may notify a family member

6. For Public health and safety - in order to prevent or lessen a serious or eminent threat to the health or

safety of a person or general public.

7. To Government agencies or Law enforcement – to identify or locate a suspect, fugitive, material

witness or missing person.

8. For military, national security, prisoner and government benefits purposes.

9. Deceased persons –discussion with coroners and medical examiners in the event of a patient’s

death.

10. Telephone calls or emails and appointment reminders -we may call your home and leave

messages regarding a missed appointment or apprize you of changes in practice hours or upcoming

events.

11. Change of ownership- in the event this practice is sold the new owners would have access to your

PHI.

1. To receive an accounting of disclosures

2. To receive a paper copy of the comprehensive “Detail” Privacy Notice

3. To request mailings to an address different than residence

4. To request Restrictions on certain uses and disclosures and with whom we release information to,

although we are not required to comply. If, however, we agree, the restriction will be in place until

written notice of your intent to remove the restriction.

5. To inspect your records and receive one copy of your records at no charge, with notice in advance

6. To request amendments to information. However, like restrictions, we are not required to agree to

them.

7. To obtain one copy of your records at no charge, when timely notice is provided (72 hours). Xrays are original records and you are therefore not entitled to them. If you would like us to outsource

them to an imaging center, to have copies made, we will be happy to accommodate you. However,

you will be responsible for this cost. Your signature below gives us permission to send your medical

records and x-rays to you on an encrypted server to the email that you provide to us.