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387 Lake Road

Suite 3

Saint Albans, VT 05478

802-527-2225

HIPAA

Privacy Notice Acknowledgement

 

I, ______________________________, hereby acknowledge that I have been given the opportunity to receive a copy of this practice’s Notice of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this Notice.

 

I also authorize Back to Health Family Chiropractic, PC to release any and all information concerning my treatment to insurance carriers, referring doctors, lawyers, and other providers involved in my care for the purpose of my treatment, payment for services rendered or daily operations involved in my care.

 

_______________________________                      ____________

Signature of Patient or Parent/Legal                      Date

Guardian if patient is a minor child

 

________________________________

Patient Name (if minor child)

 

Please list anyone other than those listed above that we are permitted to speak with regarding your care

 

________________________________                    ____________________

Name                                                                          Relationship

 

________________________________                    ____________________

Name                                                                          Relationship

 

_________________________________                  ____________________

Name                                                                          Relationship

 

I wish to be contacted in the following manner (check all that apply):

Home Telephone: __________________        □ Written Communication: _____________      

     □ O.K. to leave message with detailed            □ O.K. to mail to my home address

         information                                                  □ O.K. to mail to my work/office address

     □ Leave message with call-back                 □ O.K. to fax to this number

         number only

 □ Work Telephone _____________                     □ Other:  ____________________________

                       

     □ O.K. to leave message with detailed         ______________________________

         information

     □ Leave message with call-back                    ________________________________

         number only 

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Monday:

8:00 am - 12:00 pm

1:30 pm - 5:30 pm

Tuesday:

7:30 am - 12:00 pm

1:30 pm - 5:30 pm

Wednesday:

8:00 am - 12:00 pm

1:30 pm - 5:30 pm

Thursday:

7:30 am - 12:00 pm

1:30 pm - 4:00 pm

Friday:

8:00 am

1 pm

Saturday:

Closed *Emergencies seen.

Sunday:

Closed *Emergencies seen.