Consent for Purposes of Treatment, Payment and Healthcare Operations

I acknowledge that Contact for Health Chiropractic Center's “Notice of Privacy Practices” has been provided to me.

I understand I have a right to review Contact for Health Chiropractic Center's Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Contact for Health Chiropractic Center. The Notice of Privacy Practices for Contact for Health Chiropractic Center is also provided on request at the main administration desk of this practice and on Contact for Health Chiropractic Center's website at www.healthchiro.com. This Notice of Privacy Practices also describes my rights and Contact for Health Chiropractic Center's duties with respect to my protected health information.

Contact for Health Chiropractic Center reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by accessing Contact for Health Chiropractic Center's website, calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.