Specific postural x-rays may be necessary for the identification of the location, type, and severity of vertebral subluxation, as well as for the diagnosis and identification of latent or dangerous conditions requiring medical attention. X-rays may also be used to show progress after a period of recommended chiropractic care. At your request, you can receive a copy of your x-rays to a disc for the mandated fee of $15.00.
By signing this page below, I authorize TruRoots Chiropractic to perform diagnostic x-rays to me.
FEMALE Practice Members Only: please read carefully and check the box, then sign below if you understand and have no further questions, otherwise see our receptionist for further explanation.
I have been provided a full explanation of when I am most likely to become pregnant, and to the best of my knowledge, I am not pregnant.
By my signature below I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration, I therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.
By signing below, I recognize that I am financially responsible for all services rendered to me regardless of insurance or benefits. I further understand that any health insurance policy is an arrangement between me and my insurance carrier and that I may be required to pay for some or all of the fees charged to my account. I hereby authorize TruRoots Chiropractic to release all necessary information concerning my health condition to any billing company, insurance company, attorney, and/or adjuster in order to process any claim for reimbursement of charges incurred by me. In addition, I authorize TruRoots Chiropractic to release any information regarding my health condition to other health care providers involved in my care. This assignment will remain in effect until revoked by me in writing. I agree to a photocopy of this form is to be considered as valid as the original. I confirm that all information I have provided is true and correct to the best of my knowledge. I confirm that I have read and fully understand this agreement and authorize TruRoots Chiropractic to proceed with chiropractic tests, diagnosis, analysis, and adjustments. I give consent to receive text messages and emails from TruRoots Chiropractic.
I authorize TruRoots Chiropractic to use my testimonials, pictures, and/or videos for advertisment and/or public review including, but not limited to the reception area, Facebook, Instagram, and company website. I understand that I may revoke my testimonial at any time and will notify TruRoots Chiropractic in writing, however, I understand that the company has 45 days to act accodingly.
This notice describes how health information about you may be used and disclosed and how you can get access to your health information and records.
TruRoots Chiropractic understands the importance of privacy and we are committed to maintaining the confidentiality of your protected health information (PHI) in compliance with th Health Insurance Portability and Accountability Act of 1996 (HIPPA). We have developed office policies and procedures that protect your personal and health information when used within our office and devices used to copy or transfer this data. We assure you that your information will only be shared as required and only for the purpose of administering your case and obtaining payment for services. Be assured that without your permission, your health information will not be used for any other purpose.
The following ways are how your PHI may be used within our offices to provide you the best care and services possible:
To folllowing describes your rights regarding your PHI. You may:
If you believe that we have not properly respected the privacy of your PHI, you may file a complain with our office by calling (615) 583-9788, sending a letter to our office address: 11227 Lebanon Rd Mount Juliet TN 37122 or by emailing firstname.lastname@example.org.
I confirm that I have received and reviewed this notice and understand how health information about me may be used and disclosed and how I can get access to my health information and records.