Pediatric History Form (Page 5 of 6) in pdf

Pediatric History Form Page 5

Upper Valley Chiropractic

“A Family Health and Wellness Center”

107 S. Main St.

West Lebanon, NH 03784

Patient Authorization Re: chiropractic care in an “open adjusting” environment.

It is the practice of this office to provide chiropractic care in an “open adjusting”

environment. This “open adjusting” involves several patients being seen in the same

adjusting area at the same time. Patients are within sight of one another and some ongoing

routine details of care are discussed within earshot of other patients and staff. This

environment is used for ongoing care and is NOT the environment used for taking patient

histories, performing examinations or presenting reports of findings. These procedures are

completed in a private, confidential setting.

We are requesting this authorization of you due to various interpretations under federal law

with respect to what is known as “incidental disclosures” of health information. It is our view

that the kinds of matters related in an “open adjusting” environment are incidental matters,

in the event you or someone else would not agree with us we are providing this disclosure.

The use of this format is intended to make your experience with our office more efficient and

productive as well as to enhance your access to quality health care and health information.

If you choose not to be adjusted in an open-adjusting environment other arrangements will

be made for you. Your decision will have no adverse effect on your care from Upper Valley

Chiropractic.

Your signature indicates your authorization of this activity.

___________________________________

____/____/_______

Signature

Date

You may revoke this authorization at any time. Revocation may be accomplished by

advising us in writing of your desire to withdraw your authorization. Please allow a

reasonable processing time for the change in our procedures to be completed.

Pediatric History Form Page 5