benderchiro.com - Foot Levelers

New Patient Cancellation Policy
Welcome to Bender Chiropractic Health & Vitality Center! We look forward to serving you on your healthcare journey!

We are reserving about an hour for you to meet with your doctor and our clinical assistant, so short notice cancellations create a large gap in our schedule where we could be helping other patients.

Because of that, we ask for at least a 24-hour notice if you need to cancel or reschedule your appointment. You can call anytime, just be sure to leave a voicemail with a detailed message if you are calling after hours.

If we don’t receive a 24-hour notice, a $25 cancellation fee will be charged to your credit card on file.

Thank you!
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Notice of Privacy Practices Acknowledgement

Initial Uses Authorization Form
Effective: 4-15-2003

By signing this form, you acknowledge that you were presented with a copy of the Notice of Privacy Practices of Bender Chiropractic Health and Vitality Center. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. The most current Notice of Privacy Practices will be placed on display in the office at all times. You may obtain additional copies of our most current notice by requesting it from our privacy official, Dr. William L. Bender

Bender Chiropractic Health and Vitality Center also uses protected health information for the following reasons: (you may opt out of this authorization). Marketing; internal referral board, testimonials, pictures on bulletin board, or information unrelated to healthcare and other marketing materials. (please initial to give us authorization)
(Please initial to give us authorization)
If you have any questions regarding this notice or our health information privacy policies, please contact:
Dr. William L. Bender

You can reach the Privacy Official at: Bender Chiropractic Health and Vitality Center, 33580 Harper Avenue, Clinton Township, MI, 1-586-738-6833
Hours Available: A message may be left for our privacy official any time the clinic is open and your call will be returned within 7 business days.
Your Email address: (you may receive PHI through email)
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FOOT LEVELERS

New Patient Cancellation Policy

Notice of Privacy Practices Acknowledgement