Gregory M. McPeak, D.C., ACRB Level 1
707 Huntingdon Pike Rockledge, PA 19046 (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.