Hulsebus Chiropractic will submit your chiropractic charges to your insurance policy. You are responsible for the balance not covered by your insurance company. Co-pays are due at the time of service. Please sign that you have read and understand the financial policy.

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.  The notice contains a patient’s rights section describing your rights under the law.  You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.  You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations.  We are not required to agree with this restriction, but if we do, we shall honor this agreement.  The HIPAA law allows for the use of the information for treatment, payment or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication.  You have the right to revoke this consent in writing, signed by you.  However, such a revocation will not be retroactive.

By signing this form, I understand that:

• Protected health information may be disclosed or used for treatment, payment or healthcare operations
• The practice reserves the right to change the privacy policy as allowed by law
• The ptractice has the right to restrict the use of the information but the practice does not have to agree to thhose restrictions
• The patient has the right to revoke this consent in writing at any time and full disclosures will then cease
• The practice may condition receipt of the treatment upon execution of this consent