• Terms of Acceptance

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  • The goal of our office is to enable patients to gain control of their health. To attain this we believe communication is the key.
    There are often topics that are hard to understand and we hope this document will clarify those issues for you.
    Please read the below and if you have any questions please feel free to ask one of our staff members.

    HIPPA - Notice of Patient Privacy

    Protecting the privacy of your personal health information is very important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality insurance activities, public health and research and law enforcement activities. Any other disclosures for the purpose of treatment payment or practice operations will be made only after obtaining your consent.. You may request restrictions on your disclosures. You may inspect and receive copies of your records within 30 days of your request. You may request to view changes to your records. In the future, we may contact you for appointment reminders, announcements and to inform you about our practice and its staff. I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA) I have certain rights of privacy regarding my protected health information. I understand this information can be used to: conduct, plan and direct my treatment and follow up with multiple providers that may be treating me, obtain payment from third party payers and conduct normal health care operations such as quality assessments and physician’s certifications. The complete HIPPA manual is available upon request. I have read and understand your Notice of Privacy Practices. A more complete description may be requested.

    Missed Appointments:

    There is a possible fee charged for all appointments that are not canceled prior to scheduled visit.
    Any massage appointment that is not canceled 24 hours prior to scheduled appointment will be charged $30/$55

  • Consent to Evaluate and Treat a Minor:

    I,      being the parent or legal guardian of      , have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care.

  • Communications:

  • Acknowledgement

    I have read and fully understand the above statements.

  • Clear
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