Indicate your current problem with a Yes:

Please check all of the following that apply to you with a Yes:

I certify to the best of my knowledge, the above information is complete and accurate. If the health plan information is

not accurate, or if I am not eligible to receive a health care benefit through this practitioner, I understand that I am liable for all charges for services rendered and I agree to notify this practitioner immediately whenever I have changes in my

health condition or health plan coverage in the future.

Countries with a Level 3 Travel; Health Notice, updated by the CDC (as of 3/23/20) -Europe (Schengen Area):Austria, Belgium, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Slovakia, Slovenia, Spain, Sweden, Switzerland, -Iran-Ireland-Israel Monaco, San Marino, Vatican CityJapan -United Kingdom: England, Scotland, Wales and Northern Ireland

PATIENT RIGHTS

McPeak Family Chiropractic respects the unique differences of our patients, and will ensure that health care ethics are maintained for all patients. The following rights will be exercised on our patient's behalf:

The patient has the right to considerate and respectful care The patient has the right to, and is encouraged, to obtain from the doctor relevant, current, and understandable information concerning diagnosis, treatment, and prognosis The patient has the right to know the identity of the doctor, staff, and all involved in patient care The patient has the right to make decisions about the plan of care prior to and during the course of treatment, and to refuse a recommended treatment plan of care to the extent permitted by law, and to be informed of the consequences of this action The patient has the right to every consideration of privacy The patient has the right to expect that all communications and records pertaining to their care will be treated as confidential, except in cases where reporting is permitted or required by law The patient has the right to expect reasonable continuity of care when appropriate and to be informed by the doctor of available ad realistic patient care options

CONSENT TO TREATMENT OF A MINOR CHILD (under the age of 18)

PAYMENT, INSURANCE, MEDICAL RECORDS, AND USE OF NAME (for treatment if you accept care)

I hereby authorize release of any medical information necessary to process this claim and request payment of insurance benefits either to myself or to the party who accepts assignment. I authorize payment of any medical benefit from third-parties for benefits submitted for my claim to be paid directly to this office. I authorize the direct payment to this office of any sum now or hereafter owe this office by my attorney, out of proceeds of any settlement of my case and by any insurance company contractually obligated to make payment to me or you based upon the charges submitted for products and services rendered. I understand and agree that health and accident policies are an arrangement between an insurance carrier and me. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, fees for products

or professional services I rendered will be immediately due and payable.

AGREE TO XRAY ASSIGNMENT AGREEMENT

In the event that I receive payment for these services, I agree to promptly remit payment to the Radiologist or radiology service.

I assign my insurance benefits and rights to payment to the Radiologist to the extent of their charges, and authorize them, or their agents, to bill and release information to my insurance company, attorney, and/or any third party payer. I authorize my reading physician insurance company, attorney, and/or third-party payer to provide the radiologist or their agents with any information concerning my claim, their services, and/or payment for the services provided.

CONSENT TO CHIROPRACTIC AND/OR PHYSICAL THERAPY SERVICES

I hereby request and consent to comprehensive examinations (chiropractic and/or physical therapy, orthopedic and/or neurological), Chiropractic adjustments/treatments (and any other procedures including various modes of physiotherapy modalities), physical therapy intervention (including soft tissue mobilization, therapeutic exercises, stretching, posture and ergonomic training, and home exercise program, nutritional counseling/advice, and diagnostic x-rays) by McPeak Family Chiropractic and its staff, who now or in the future reside in this office. I have had an opportunity to discuss with McPeak Family Chiropractic's staff, the nature and purpose of the treatment indicated. I understand the results are not guaranteed and am informed that in the practice of medicine, in the practice of chiropractic, and in the practice of physical therapy, there are some risks to treatment, including but not limited to: fractures, disc injuries, strokes, dislocations, and sprains. I do not expect the doctor(s) to be able to anticipate and explain all risks and complications, and wish to rely on the doctor(s) to exercise judgement during the course of any procedure which the doctor(s) feels at the time is in

mybest interest. I have read, or have had read to me, the full above consent and have also had an opportunity to ask questions about

its content and by signing below I agree to the above terms and procedures. I intend this consent to cover any treatment for my present condition and for any future conditions for which I seek treatment by McPeak Family Chiropractic and/or employed staff.

NO SHOW/CANCELLATION POLICY

McPeak Family Chiropractic has the right to charge a fee of $60.00 for any cancelations done without at least 24 hours' notice of your scheduled appointment. Payment will be due upon next visit. If patient shows up for appointment more than 15 minutes late, we may reschedule or full treatment may not be rendered.

By my signature below, I acknowledge that I have read, understand, and agree to the above provisions, and I assign my insurance

Gregory M. McPeak, D.C., ACRB Level 1

207 Tulpehocken Ave Elkins Park, PA 19027 (215)379-0640

M/W/F: 9am-12:30 & 2:30-7pm Tuesday: 2-7pm

Our Summary Notice of Privacy provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do. We shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations, you have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. McPeak Family Chiropractic provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA

Protected health information may be disclosed or used for treatment, payment, or health care operations. McPeak Family Chiropractic has a summary notice of Privacy Practices and that the patient has the opportunity to review

McPeak Family Chiropractic reserves the right to change the notice of Privacy Policies. The patient has the right to restrict the use of their information but McPeak Family Chiropractic does not have to agree to those restrictions. Any restrictions will be reviewed by our HIPAA Compliance Committee and the patient will be notified of

The patient may revoke this consent in writing at any time and all future disclosures will then cease. Requests will be forwarded to the SFEA HIPAA Compliance Committee. McPeak Family Chiropractic may condition treatment upon the execution of the Consent.