Medical History Intake Form (Page 8 of 8) in pdf

Medical History Intake Form Page 8

Release Chiropractic HIPAA Acknowledgement

Patient Acknowledgment and Receipt of Notice of Privacy Practices Pursuant

to HIPAA and Consent for Use of Health Information

Patient Name: ___________________________________________

Date of Birth: ___________________________________________

The undersigned does hereby acknowledge that he or she has received a copy of this office’s Notice of Privacy

Practices Pursuant to HIPAA and has been advised that a full copy of this office’s HIPAA Compliance Manual

is available upon request.

The undersign does hereby consent to the use of his or her health information in a manner consistent with the

Notice of Privacy Practices Pursuant to HIPAA, the HIPAA Compliance Manual, State Law, and Federal Law.

Date: _____________________________________________

By: ______________________________________________

Patient’s Signature

If patient is a minor or under a guardianship order as defined by State law:

By: ______________________________________________

Signature of Parent/Guardian (circle one)

Release Chiropractic and Wellness Center, 640 East Eisenhower Blvd. Suite 100, Loveland, CO 80537

Medical History Intake Form Page 8