Note: To do in clinic. Please mark the areas on the diagram with the following letters to describe your symptoms:

R= Radiating B=Burning D=Dull A=Aching N=Numbness S=Sharp T=Tingling

Instructions: Please read carefully.

Where do you feel pain? Please answer questions for each area of complaint.

Note: 0 is equal to no pain and 10 is equal to worst possible pain.

REGENERATIVE MEDICINE

We can include a free consult with our nurse practitioner for any of the following treatments. Would you be interested in any of the following:

Please mark P for in the Past, and C for Current.

REGARDING: Chiropractic Adjustments, Modalities, and Therapeutic Procedures.

I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risk are most often very minimal, in rare cases, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke, which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments.

Treatment objectives as well as the risks associated with chiropractic adjustments and, all other procedures provided at Innovative Chiropractic have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care.

REGARDING: Payments.

I hereby authorize payment to be made directly to Innovative Chiropractic, for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Innovative Chiropractic for any and all services I receive at this office.

REGARDING: X-rays/Imaging Studies.

FOR WOMEN ONLY

Please read carefully and include the appropriate date, then sign below if you understand and have no further questions, otherwise see our receptionist for further explanation.

Date 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.

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. Once you have read this notice, please sign the last page, and return only the signature page (page 2) to our front desk receptionist. Keep this page for your records.

• Treatment purposes- discussion with other health care providers involved in your care
• 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.
• For payment purposes - to obtain payment from your insurance company or any other collateral source.
• For workers compensation purposes- to process a claim or aid in investigation
• Emergency- in the event of a medical emergency we may notify a family member
• 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.
• To Government agencies or Law enforcement – to identify or locate a suspect, fugitive, material witness or missing person.
• For military, national security, prisoner and government benefits purposes.
• Deceased persons –discussion with coroners and medical examiners in the event of a patient’s death.
• 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 up-coming events.
• Change of ownership- in the event this practice is sold, the new owners would have access to your PHI.

• To receive an accounting of disclosures
• To receive a paper copy of the comprehensive “Detail” Privacy Notice
• To request mailings to an address different than residence
• 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.
• To inspect your records and receive one copy of your records at no charge, with notice in advance
• To request amendments to information. However, like restrictions, we are not required to agree to them.
• To obtain one copy of your records at no charge, when timely notice is provided (72 hours X-rays 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. COMPLAINTS: If you wish to make a formal complaint about how we handle your health information, please call at (720) 439-7890. If she is unavailable, you may leave a message and she will call you back to schedule an appointment within 72 hours or 3 working days. If you are still not satisfied with the manner in which this office handles your complaint, you can submit a formal complaint to:

DHHS, Office of Civil Rights 200 Independence Ave. SW Room 509F HHH Building Washington DC 20201

I have been explained Innovative Chiropractic’s Patient Privacy Notice. I understand my rights as well as the practices duty to protect my health information, and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this ‘Notice of Privacy Practice” at any time in the future and will make the new provisions effective for all information that it maintains past and present.

I am aware that a more comprehensive version of this “Notice” is available to me and several copies kept in the reception area. At this time, I do not have any questions regarding my rights or any of the information I have received.