Chiropractic Appointment Reminder Letter Template Page 5
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9Complete Chiropractic & Bodywork Therapies
2020 Hogback Rd. Suite 7
Ann Arbor, MI 48105
(734) 677-1900
NOTICE OF PRIVACY PRACTICES
Per HIPAA REGULATIONS
Consent for Purposes of Treatment, Payment and Healthcare Operations
THIS NOTICE DESCRIBES HOW MEDICAL/PROTECTED HEALTH
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
I acknowledge that Complete Chiropractic & Bodywork Therapies “Notice of
Privacy Practices” has been provided to me.
I understand I have the right to review Complete Chiropractic & Bodywork
Therapies Notice of Privacy Practices prior to signing this document. 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 bills or in the
performances of healthcare operations at Complete Chiropractic & Bodywork
Therapies. The Notice of Privacy Practices is also provided on request at the
main administration desk. This notice of Privacy Practices also describes my
rights and Complete Chiropractic & Bodywork Therapies duties with respect to
my protected health information.
Complete Chiropractic & Bodywork Therapies reserves the right to change the
Privacy Practices that are described in the Notice of Privacy Practices. I may
obtain a revised notice of Privacy Practices by calling the office and requesting a
revised copy to be sent via mail or may request a copy at the time of my next
scheduled appointment.
_____________________________
______________
Signature of Patient or Patient Representative
Date
___________________________________________
Name of Patient or Patient Representative
___________________________________________
Description of Patient Representative’s Authority
___________________________________________
_____________________
Staff Witness
Date
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