Consent Related to Privacy Notice:
I have had a chance to review the Practice Privacy Notice as part of this registration process. I understand that the terms of the Privacy Notice may change and I may need to obtain these revised notices by contacting the practice by phone or in writing. I understand I have the right to request how my protected health information (PHI) has been disclosed. I also have the right to restrict how the information is disclosed, but this practice is not required to agree to my restrictions. IF it does agree to my restrictions on PHI use, it is bound by that agreement.
Consent For Care:
I, with my signature, authorize South Pointe Healthcare and South Pointe Chiropractic, and any employee working under the direction of the providers, to provide medical care for me, or to this patient for which I am the legal guardian. This medical care may include, but is not limited to, Primary Care services, Chiropractic services, Massage Therapy services, Acupuncture services, Mental health counselling, Myer’s IV therapy, Trigger point injections, and physical rehab services.This medical care may include services and supplies related to my health (or the identified person) and may include (but not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale of dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment.
I hereby authorize South Pointe Healthcare and South Pointe Chiropractic and its providers to perform examinations and therapeutic procedures that are considered medically necessary according to my diagnosis and treatment plan. I authorize South Pointe Healthcare and South Pointe Chiropractic to obtain/have access to my medication history. Clinicians authorized to treat me may include: Medical Doctors, Physician Assistants, Chiropractors, Physical Therapists, Acupuncturists, Massage Therapists, Mental Health providers, Nurses as well as assistants to these providers.
As with any health procedure, complications may arise during or after treatment. These complications include soreness, muscle or ligament strain, dislocations, fractures, stroke, disk injuries or physiotherapy skin irritation. These are extremely rare occurrences. I understand that I have the right to refuse any treatment or procedure and have the right to discuss all treatments with my provider. I acknowledge that I have been given risks and benefits of care offered and accept these risks to possible care provided.
If applicable, Legal Representatives sign below:
By signing this form, I represent that I am the legal representative of the Member identified above and will provide written proof (e.g., Power of Attorney, living will, guardianship papers, etc.) that I am legally authorized to act on the Member’s behalf with respect to this authorization form.