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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         ______________________________


     □ Leave message with call-back                    ________________________________

         number only 

New patients receive a Free Consultation.


Sign-up using the form or call us at 802-527-2225 to take advantage of this exclusive offer.

THIS ---->https://drmolly.com/forms/hipaa.html

Office Hours

Monday8am - 12pm1:30pm - 5pm
Tuesday8am - 12pm1:30pm - 6pm
Wednesday8am - 12pm1:30pm - 6pm
Thursday8am - 12pm2pm - 5pm
Friday8am - 12pm1:30pm - 3pm
SaturdayClosed *Emergencies seen.
SundayClosed *Emergencies seen.
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8am - 12pm 8am - 12pm 8am - 12pm 8am - 12pm 8am - 12pm Closed *Emergencies seen. Closed *Emergencies seen.
1:30pm - 5pm 1:30pm - 6pm 1:30pm - 6pm 2pm - 5pm 1:30pm - 3pm


The staff was very nice and caring. I recommend you to go if needed. from Dr. Keefe.

Cindy M.
St. Albans, VT

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