Pediatric History Form Page 4
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5Ferguson Family Chiropractic
4609 South Main St. Acworth, GA 30101
((770)966-1800
HEALTH CARE AUTHORIZATION FORM
I have been provided with a copy of the Notice of Privacy Practice for Protected Health
Information. The Notice of Privacy Practices describes the types of uses and disclosures of
my Protected Health Information (PHI) that will occur in my treatment, payment of my bills or
in the performance of health care operations of this chiropractic office. A copy of our notice is
attached and we encourage you to read it and request your own copy if you would like one.
This Notice of Privacy Practices also describes my rights and duties of the Chiropractor with
respect to my protected health information. Thereby give permission to Ferguson Family
Chiropractic (FFC) to use and/or disclose Protected Health Information in accordance with the
following:
SPECIFIC AUTHORIZATIONS:
I give permission to FFC to use my address. Phone number and clinical records to
contact me with appointment reminders, missed appointment notifications, birthday
cards, holiday related cards, newsletters, information about treatment alternatives
or other health related information.
If FFC contacts me by phone, I give them permission to leave a phone message on
my answering machine or voicemail.
I give permission to FFC to use my name on a welcome board, referral board, and
birthday board.
l give permission to FFC to use my photograph on their patient picture bulletin
board and other marketing materials such as their brochure, website and ads in
print media.
I give permission to FFC to use any testimonial written by me for marketing
purposes such as sharing
with other patients or potential patients, in their brochure, on their website or in ads
in print media.
I give FFC permission to treat me in an open room where other patients are also
being treated. I am aware that other persons in the office may overhear some of my
protected health information during the course of care. Should l need to speak with
a doctor at any time in private, the doctor will provide a room for these
conversations.
By signing this form you are giving FFC permission to use and disclose your protected health
information in accordance with the directives listed above. 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. This authorization will remain in
effect for the duration of my care at Ferguson Family Chiropractic plus 7 years or until
revoked by me.
(more)
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