Patient Refusal Information Sheet (Page 4 of 8) in pdf

chiropractic care, to work with my child’s condition through the use of adjustments and procedures the doctor deems appropriate.

I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for

payment. I agree that I am responsible for all bills incurred at this office. The Dr. will not be held responsible for any pre-existing

medically diagnosed conditions nor for any medical diagnosis. I also understand if I suspend or terminate my care for any reason,

any fees for professional services rendered me will become immediately due and payable. I grant permission for my minor child to

be treated by the provider(s) at Oceanside Chiropractic, LLC.

_________________________________________________________________________________________________________________________________________________

PARENT OR GUARDIAN AUTHORIZING CARE SIGNATURE

DATE

Patient Health Information Consent Form

We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights

concerning those records. Before we will begin any health care operations we must require you to read and sign this

consent form stating that you understand and agree with how your records will be used. If you would like to have a

more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we

encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.

1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI)

for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient

agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies)

provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI

to the minimum needed for what the insurance companies require for payment.

2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request

corrections. The patient may request to know what disclosures have been made and submit in writing any further

restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.

3. A patient's written consent need only be obtained one time for all subsequent care given the patient in this office.

4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use

of those records for the care given prior to the written request to revoke consent but would apply to any care given

after the request has been presented.

5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy

official has been designated to enforce those procedures in our office. We have taken all precautions that are known

by this office to assure that your records are not readily available to those who do not need them.

6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these

policies and procedures.

7. Our office has the right to contact patients using information provided on the Case History form including mail,

phone, or email as long as appropriate measures are taken to protect PHI.

8. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the

chiropractic physician has the right to refuse to give care.

I have read and understand how my Patient Health Information will be used and I agree to these policies and

procedures.

Print Name of Patient ____________________________________________Date _________________

Patient Signature_____________________________________________________________________

Signature of Parent or Guardian (if a minor)________________________________________________

Relationship to Minor _____________________

Dr. Heather Hunscher, DC * 105 Franklin St, Unit 11 * Westerly, RI * 02891 * 401-757-0408

Rev 3/15

Patient Refusal Information Sheet Page 4