Pediatric History Form Page 3
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6Upper Valley Chiropractic
“A Family Health and Wellness Center”
107 S. Main St.
West Lebanon, NH 03784
Form: Consent for Purpose of Treatment, Payment and Health Care Operations
I consent to the use or disclosure of my protected health information by Amber McLelland, DC for the purpose
of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health
care operations of Amber McLelland, DC.
I understand that diagnosis or treatment of me by Upper Valley Chiropractic may be conditioned upon my
consent as evidenced by my signature on this document.
I understand I have the right to request a restriction as to how my protected health information is used or
disclosed to carry out treatment, payment or health care operations of the practice. Upper Valley Chiropractic
is not required to agree to the restrictions that I may request. However, if Amber McLelland, DC agrees to a
restriction that I may request. the restriction is binding on Amber McLelland, DC and Upper Valley
Chiropractic.
I have the right to revoke this consent in writing, at any time, except to the extent that Upper Valley
Chiropractic or Amber McLelland, DC has taken action in reliance on this consent.
My “protected health information” means health information, including my demographic information collected
from me and created or received by my physician, another health care provider, a health plan, my employer, or
a health care clearinghouse. This protected health information relates to my past, present or future physical or
mental health or condition and identifies me, or there is a reasonable basis to believe the information may
identify me.
I understand I have a right to review Amber McLelland, DC’s Notice of Privacy Practices prior to signing this
document.
Amber McLelland, DC’s Notice of Privacy Practices has been provided to me.
The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information
that will occur in my treatment, payment of my bills or in the performance of health care operations of the
Upper Valley Chiropractic.
The Notice of Privacy Practices also describes my rights and the duties of Upper Valley Chiropractic with
respect to my protected health information.
The Notice of Privacy Practices for Upper Valley Chiropractic is also provided at 107 S. Main St. #10, West
Lebanon, NH 03784 and on the Upper Valley Chiropractic web-site.
The Notice of Privacy Practices also describes my rights and the duties of Upper Valley Chiropractic with
respect to my protected health information.
Amber McLelland, DC reserves the right to change the privacy practices that are described in the Notices of
Privacy Practices.
I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in
the mail or asking for one at the time of my next appointment.
______________________________________
Signature of Patient or Personal Representative
______________________________________
Name of Patient or Personal Representative
_____/______/_______
Date
__________________________________________
Description of Personal Representative’s Authority
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