Family Health History Template (Page 8 of 8) in pdf

(HIPPA Authorizations)

Mix Family Chiropractic-

1. Patient Authorization regarding chiropractic care being provided in an “open adjusting”

environment:

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

“Open adjusting” involves several patients being seen in the same adjusting room 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 an “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.

2. Patient Authorization for appointment reminders and scheduling related matters:

It is our desire for our staff to use your name, address and/or telephone number for the purpose

of contacting you to remind you about scheduled appointments, re-evaluations or other

appointment related issues.

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 agree to any of the above, other arrangements will be made for you. Your decision

will have no adverse effect on your care from Mix Family Chiropractic or on your relationship

with our staff.

Your signature indicates your authorization of these activities.

____________________

___________________ ___________

Name (printed)

Signature

Date

This authorization may be revoked by you 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

system to be completed.

Family Health History Template Page 8