HEALTH CARE AUTHORIZATION FORM
I have been provided with a copy of the Notice of Privacy Practices for Protected Health Information. The Notice of Privacy Practices describes the types of uses and disclosures of my Protected Health Information (PHI) that will occur in my care, payment of my bills or in the performance of health care operations of this chiropractic office. A copy of our notice is attached and we encourage you to read it and request your own copy if you would like one.
This Notice of Privacy Practices also describes my rights and duties of the Chiropractor with respect to my protected health information. I hereby give permission to Health Path Chiropractic to use and/or disclose Protected Health
Information in accordance with the following:
• I give permission to Health Path Chiropractic to use my address, phone number and clinical records to contact me with appointment reminders, missed appointment notification, birthday cards, holiday related cards, newsletters, information about treatment alternatives or other health related information.
• If Health Path Chiropractic contacts me by phone, I give them permission to leave a phone message on my answering machine or voice mail.
• I give permission to Health Path Chiropractic to use my name on a welcome board, referral board, and birthday board.
• I give permission to Health Path Chiropractic to use my photograph on their patient picture bulletin board and other marketing materials such as their brochure, website and ads in print media.
• I give permission to Health Path Chiropractic to use any testimonial written by me for marketingpurposes such as, sharing with other patients or potential patients, in their brochure, on their website or inads in print media.
• I give Health Path Chiropractic permission to analyze/adjust me in an open room where other patients are also receiving care. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with the doctor at any time in private, thedoctor will provide a room for these conversations.
• By signing this form you are giving Health Path Chiropractic permission to use and disclose your protected health information in accordance with the directives listed above.
The use of this format is intended to make your experience with our office more efficient and productive, as well as to enhance your access to quality health care and health information. This authorization will remain in effect for the duration of my care at Health Path Chiropractic plus 7 years or until revoked by me.
RIGHT TO REVOKE AUTHORIZATION:
You have the right to revoke this AUTHORIZATION, in writing, at any time. However, your written request to revoke this AUTHORIZATION is not effective to the extent that we have provided services or taken action in reliance on your authorization. You may revoke this AUTHORIZATION by mailing or hand delivering a written notice to the Privacy Official of Health Path Chiropractic.
The revocation is not effective until it is received by the Privacy Official.
This AUTHORIZATION is requested by Health Path Chiropractic for its own use/disclosure of PHI.
(Minimum necessary standards apply.)
I have the right to refuse to sign this AUTHORIZATION.
I have the right to inspect or copy, within boundaries, the protected health information to be used/disclosed. A copy of the signed authorization will be provided to me.
I have read and understand this Healthcare Authorization Form and acknowledge receipt of The Notice of Privacy
We encourage and support a shared decision making process between us regarding your health needs. As a part of that process you have a right to be informed about the condition of your health and the recommended care and adjustments to be provided to you so that you can make the decision whether or not to undergo such care with full knowledge of the known risks. This information is intended to make you better informed in order that you can knowledgeably give or withhold your consent.
Chiropractic is based on the science which concerns itself with the relationship between structures (primarily the spine) and function (primarily of the nervous system) and how this relationship can affect the restoration and preservation of health.
Adjustments are made by chiropractors in order to correct or reduce neurological imbalances.
The primary goal in chiropractic care is the removal and/or reduction of neurological imbalances.
A chiropractic examination will be performed which may include spinal and physical examination, orthopedic and neurological testing, palpation, specialized instrumentation, radiological examination (xrays).
The chiropractic adjustment is the application of a precise movement and/or force into the spine in order to reduce or correct neurological imbalance(s). There are a number of different methods or techniques by which the chiropractic adjustment is delivered but are typically delivered by hand. Some may require the use of an instrument or other specialized equipment. In addition, physiotherapy or rehabilitative procedures may be included in the management protocol.
In addition to the benefits of chiropractic care and adjustments, one should also be aware of the existence of some risks and limitations of this care. The risks are seldom high enough to contraindicate care and all health care procedures have some risk associated with them.
Risks associated with some chiropractic adjustments may include soreness, musculoskeletal sprain/strain, and fracture. In addition there are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and effect relationship between chiropractic adjustments and the occurrence of stroke; rather, recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in process. However, you are being informed of this reported association because a stroke may cause serious neurological impairment.
I have been informed of the nature and purpose of chiropractic care, the possible consequences of care, and the risks of care, including the risk that the care may not accomplish the desired objective. Reasonable alternative treatments have been explained, including the risks, consequences and probable effectiveness of each. I have been advised of the possible consequences if no care is received. I acknowledge that no guarantees have been made to me concerning the results of the care.
I HAVE READ THE ABOVE PARAGRAPHS. I UNDERSTAND THE INFORMATION PROVIDED.
ALL QUESTIONS I HAVE ABOUT THIS INFORMATION HAVE BEEN ANSWERED TO MY SATISFACTION. HAVING THIS KNOWLEDGE, I KNOWINGLY AUTHORIZE
TO PROCEED WITH CHIROPRACTIC CARE PROVIDE YOUR SIGNUATURE.