I understand that I have certain rights of privacy regarding my protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:
A. Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
B. Obtain payment from third party payors.
C. Conduct normal healthcare operations such as quality assessments and physician certifications. I acknowledge that I may request your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I also understand that I may request, in writing, that you restrict how my private information is used or disclosed to carry our treatment, payment, or healthcare operation. I also understand you are not required to agree to my requested restrictions, but if agree, then you are bound to abide by such restrictions.
In order to provide the most effective healing environment, most effective application of Chiropractic procedures, and the strongest possible doctor-patient relationship, it is our wish to provide each patient with a set of parameters and declarations that will facilitate the goal of optimum health through Chiropractic.
To that end, we ask that you acknowledge the following point regarding Chiropractic care and the services that are offered through clinic.
A. Chiropractic is a very specific science, authorized by law to address spinal health concerns and needs. Chiropractic is a separate and distinct science, art, and practice. It is not the practice of medicine.
B. Chiropractic seeks to maximize the inherent healing power of the human body by restoring normal nerve functions throughout the adjustment of spinal subluxation(s). Subluxations are deviations from normal spinal structures and configurations that interfere with normal nerve processes.
C. The Chiropractic adjustment process, as defined in the law as this jurisdiction, involves the application of a specific directional thrust to a region or regions of the spine with specific intent of re-positioning misaligned spinal segments. This is a safe, effective procedure applies over one million time each day by doctors of Chiropractic in the United States alone.
D. A thorough Chiropractic examination and evaluation as part of the standard Chiropractic procedure. The goal of this process is to identify any spinal health problems or Chiropractic needs. If during this process, any condition or question outside the scope of Chiropractic is identified you will receive a prompt referral to an appropriate provider or specialist according to the initial indications of the need.
E. Chiropractic does not seek to replace or compete with your medical, dental, or any other type(s) of health professionals. They retain responsibility for care and management of medical conditions. We do not offer advice regarding treatment prescribed by others.
F. Your compliance with care plans, home and self-care, ect., is essential to maximum healing and optimal health through Chiropractic.
G. We invite you to speak frankly to the doctor on any matter related to your care at this facility, it's a nature, duration, or cost, in what we work to maintain as a supporting, open environment.
By my signature below, I have read and fully understand the above statements. All questions regarding the doctor's objectives pertaining to my care in this office have been answered to my satisfaction, I thereby accept Chiropractic care on this basis.
