Family Health History Template Page 7
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8may no longer be protected by the
federal privacy rules.
We reserve the right to alter or amend
the terms of this privacy notice. If
We normally provide information about
changes are made to our privacy notice
your health to you in person at the time
we will notify you in writing as soon as
you receive chiropractic care from us.
possible following the changes. Any
We may also mail information to you
change in our privacy notice will apply
regarding your health care or about the
for all of your health information in our
status of your account. If you would like
files.
to receive this information at an address
other than your home or, if you would
If you have a complaint regarding our
like the information in a specific form
privacy notice, our privacy practices or
please advise us in writing as to your
any aspect of our privacy activities you
preferences.
should direct your complaint to:
Dr. Matthew Mix
You have the right to inspect and/or copy
your health information for as long as the
If you would like further information
information remains in our files. In addition
about our privacy policies and practices
you have the right to request an amendment
please contact:
to your health information. Requests to
Dr. Michelle Mix
inspect, copy or amend your health related
information should be provided to us in
You also have the right to lodge a
writing.
complaint with the Secretary of the
We are required by state and federal
Department of Health and Human
law to maintain the privacy of your
Services. If you choose to lodge a
patient file and the health protected
complaint with this office or with the
health information therein. We are also
Secretary your care will continue and
required to provide you with this notice
you will not be disadvantaged by this
of our privacy practices with respect to
office or our staff in any manner
your health information. We are further
whatsoever.
required by law to abide by the terms of
this notice while it is in effect.
This notice is effective as of
. This notice, and any alterations
or amendments made hereto will expire seven years after the date upon which the
record was created. My signature acknowledges that I have received a copy of this
notice.
____________________________
__________________________
________
Name (Printed please)
Signature
Date
If you are a minor, or if you are being represented by another party
____________
________
Personal Representative Printed Personal Representative Signature
Date
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