I understand that I am directly and fully responsible to Innovative Chiropractic for all fees associated with chiropractic care my child

The risks associated with exposure to ionization and spinal adjustments have been explained to me to my complete satisfaction, and I have conveyed my understanding of these risks to the doctor. After careful consideration I do hereby request and authorize imaging studies and chiropractic adjustments for the benefit of my minor child for whom I have the legal right to select and authorize health

Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse / former spouse or other guardian is not required. If my authority to so select and authorize this care should change in any way, I will immediately notify

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

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.

PERMITTED DISCLOSURES

1. Treatment purposes- discussion with other health care providers involved in your care. 2. 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. 3. For payment purposes - to obtain payment from your insurance company or any other collateral source. 4. For workers compensation purposes- to process a claim or aid in investigation. 5. Emergency- in the event of a medical emergency we may notify a family member. 6. 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. 7. To Government agencies or Law enforcement - to identify or locate a suspect, fugitive, material witness or missing

8. For military, national security, prisoner and government benefits purposes. 9. 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. 11. Change of ownership- in the event this practice is sold, the new owners would have access to your PHI.

YOUR RIGHTS

1. To receive an accounting of disclosures. 2. To request mailings to an address different than residence 3. 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

4. To inspect your records and receive one copy of your records at no charge, with notice in advance. 5. To request amendments to information. However, like restrictions, we are not required to agree to them. 6. 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 the Clinic Director at (720) 439-7890. If she is unavailable, you may leave a message and she will call you back to make 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 received a copy of 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.

At this time, I do not have any questions regarding my rights or any of the information I have received.