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