CONFIDENTIAL PATIENT DATA

1. On the diagrams below, please use these symbols to identify your symptoms:

Aching= A	Burning= B
Stabbing= S	Numbness= N
Pins & Needles= P	Other= O

Functional Rating Index

For use with Neck and/or Back Problems only.
In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities. For each item below, please circle the number which most closely describes your condition right now.

2810-A Bragg Blvd
Fayetteville, NC 28303
910-860-3050
910-860-3080 fax

I have notified Royal Chiropractic Center of my current medical insurance and mailing address.

I am aware of the Notice of Privacy Practices of Royal Chiropractic Center located in new patient packet.

Consent for Chiropractic Care

I hereby request that Dr. Dennis Royal, D.C. provide chiropractic service for me (or my minor child, whose name appears below). I understand that care is to be provided by Dr. Dennis Royal, D.C. or his designated assistant. Dr. Dennis Royal, D.C. will discuss my care with me and I understand that:

1. The purpose of chiropractic care is to contribute to health by the location, analysis, and correction of vertebral subluxations for the restoration of normal nerve functioning.
2. Chiropractic is a separate and distinct profession and is not the practice of medicine. Therefore, diagnosis of medical conditions is not a primary goal. However, I will be informed of abnormal findings.
3. Chiropractors do not give medical advice, nor do they discourage me from receiving medical advice. If deemed advisable, Dr. Dennis Royal, D.C. will refer me for medical advice and/or diagnosis. Dr. Dennis Royal, D.C. will offer service with all possible diligence.
4. Dr. Dennis Royal, D.C. uses only chiropractic methods that are taught in accredited colleges and appropriate techniques will be selected for my spinal care based upon standard professional protocols.
5. Chiropractic adjustments are exceedingly safe when applied properly. However, all actions in life come with some risk, including chiropractic adjustments.
6. Although the risks are minimal, there have been rare reports of vertebral artery damage, fractures, and aggravation of disc condition associated with chiropractic procedures.
7. Because a small force is introduced to the spine during adjustments there may be temporary minor musculoskeletal discomfort.
8. I am an active participant in my chiropractic care, and I am therefore invited to ask any questions or express any concerns that I may have.
9. That I am free to withdraw my consent and discontinue care at any time.

Note:
Payment is expected as services are rendered; therefore please understand that payment for services rendered on the first visit is due prior to your leaving the office unless other arrangements are made (i.e. medical insurance, Worker's Compensation, attorney, or automobile medical coverage, etc.). Upon release from care, if no payment has been received in 90 days, Royal Chiropractic may directly bill the insurance company (i.e. med-pay, health insurance, liable party, etc.) for payment toward your outstanding medical bill.

Missed Appointment Policy

At Royal Chiropractic Center, your time is valued. Dr. Royal strives to see patients in a timely manner. We respect your time and ask you to respect our time and other patients' needs by keeping your appointment. Each appointment time slot is important and cannot be recovered if a patient chooses not to keep their appointment. We collect fees to ensure that Dr. Royal can continue to see patients. Please keep in mind that each skipped or missed appointment is not just time lost, but also time when other patients cannot be seen.

Please refer to the guidelines below to learn more about our missed appointment policy:

• It is your responsibility to provide us with a working telephone number to allow us to communicate important information, such as x-ray results, and provide telephone reminder of scheduled appointments. Having a valid telephone number is truly important; please help us to maintain your records.
• Effective July 1, 2015 each missed appointment will be flagged and you will receive a notice that you have missed your appointment. In addition, your account will be assessed a $25.00 missed appointment fee. Please note that the fee will not be billed to your insurance.
• Any Cancellation not made at least 24 hours before the scheduled appointment is considered a missed appointment and subject to the terms above.
• If you arrive 20 minutes late for your scheduled appointment, without prior notification to our office, this may also be considered a missed appointment. Please remember that communicating with our office is critical to us providing you with quality health care.

We understand that circumstances occur that do not allow you to keep your scheduled appointment. If this is the case, please call and discuss this with the office staff as soon as possible. We will waive the cancellation fee for this appointment as long as you do not have a history of cancellations. Our schedule fills up quickly, and this will allow other patients to fill those slots.
We realize that there are times that you may arrive for a scheduled appointment time and are not able to be seen promptly at your appointed time. Please know that we go out of our way to make certain that this does not happen, however due to patient emergencies or other unexpected incidents, our schedule may occasionally fall behind.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

YOUR RIGHTS

Get an electronic or paper copy of your medical record
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say "no" to your request, but we'll tell you why in writing within 60 days.

Request confidential communications
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say "yes" to all reasonable requests.

Ask us to limit what we use or share
You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care.
ONLY if you pay for a service or health care item out-of-pocket, in full, at the time of service, can we comply with your request not to share that information for the purpose of payment or our operations with your health insurer. (i.e. comply with your request not to file your claims to your insurance company). Otherwise, we will say "yes" unless a law requires us to share that information.

Get a list of those with whom we've shared information
You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. 

File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting us. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877- 696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

YOUR CHOICES

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Contact you for fundraising efforts

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information

In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again.

OUR USES AND DISCLOSURES

How do we typically use or share your health information? We typically use or share your health information in the following ways.

• Treat you
  We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
• Run our organization
  We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.
• Bill for your services
  We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information? We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.
For more information: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

Help with public health and safety issues
We can share health information about you for certain situations such as preventing disease; helping with product recalls; reporting adverse reactions to medications; reporting suspected abuse, neglect, or domestic violence; and, preventing or reducing a serious threat to anyone's health or safety.

Do research
We can use or share your information for health research.

Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.

Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers' compensation, law enforcement, and other government requests
We can use or share health information about you for workers' compensation claims, for law enforcement purposes, or with a law enforcement official. We can also use or share health information about you with health oversight agencies for activities authorized by law for special government functions such as military, national security, and presidential protective services.

Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.

OUR RESPONSIBILITIES

We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Effective September 23, 2013