largechiropracticclinic.com - Patient Authorization (HIPAA Form)

Patient Authorization

HIPAA / Patient Rights & Cancellation Policy
Authorization to Use and Disclose Protected Health Information
I authorize Large Chiropractic Clinic to discuss my personal health information (PHI), as permitted by HIPAA, with the following people:
Name and Relationship
Patient Rights
I may revoke this authorization by submitting a written revocation to the office/privacy officer. Information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations. Treatment or payment will not be conditioned on providing this authorization.

By signing below, I confirm that I understand and agree to the above authorization and rights.
Patient / Legally Authorized Individual Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Print Patient’s Full Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Witness Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cancellation / No-Show Policy
Please cancel appointments at least 24 hours in advance. Appointments canceled with less than 24 hours’ notice or missed without notice will be billed a $30.00 missed-appointment fee.

We understand emergencies and work or family obligations may sometimes prevent advance notice. Providing timely notice allows another patient to use the appointment.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed Name of Patient/Responsible Party
Signature of Patient/Responsible Party
Witness Signature
Patient Requests a Copy of This Policy
Should be Empty:

Patient Authorization

Authorization to Use and Disclose Protected Health Information

Patient Rights

Cancellation / No-Show Policy