Pediatric History Form (Page 4 of 6) in pdf

Upper Valley Chiropractic

“A Family Health and Wellness Center”

107 S. Main St.

West Lebanon, NH 03784

Form Notice of Privacy Practice Summary

This summary discloses how health information about you may be used. A full notice of

your privacy rights has also been provided to you.

Upper Valley Chiropractic uses health information about you for treatment, to obtain

payment for treatment with your authorization as required (check your state laws), for

administrative purposes and to evaluate the quality of care that you receive.

Upper Valley Chiropractic will not disclose your information to others unless you tell us to do

so or unless the law authorizes or requires us to do so.

Upper Valley Chiropractic may use your information to provide appointment reminders and

information about alternatives or other health-related issues.

Upper Valley Chiropractic may disclose your information for public health activities, to

funeral directors to enable them to carry out their activities, for organ and tissue donations,

research health and safety, governmental function in order to comply with workers

compensation laws and regulations a right to request restriction, report and retain a copy of

your health record, request communication of your information by alternative means at

alternative locations, revoke your authorization and request an accounting of your health

records.

You may complain to the Privacy Officer Amber McLelland, D.C. and to the Department of

Health and Human Services if you believe your privacy rights have been violated. You will

not be retaliated against for filing a complaint.

Upper Valley Chiropractic must maintain the privacy of protected health information, provide

you with notice of its legal duties and privacy practices with respect to your health

information, abide by the terms of the notice, notify you if it was unable to agree to the

requested restriction on how your information is used or disclosed, accommodate

reasonable requests you may make to communicate with health information by alternative

means or by alternative locations and obtain your written authorization to use or disclose

your health information for reasons other than those listed above and permitted under law.

If you have any questions or complaints please contact Amber McLelland, D.C. At 603-298-

7400

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Signature

Date

Pediatric History Form Page 4