Patient Financial Responsibility Form (Page 2 of 2) in pdf

Fountain Chiropractic

Consent for Purposes of Treatment, Payment & Healthcare Operations (3/03)

In this document, “I” and “my” refer to the patient,

and “Chiropractor” refers to Dr. Arnold A. Moran.

I consent to the use or disclosure of my protected health information by Chiropractor for the purpose of

analyzing, diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct

health care operations of Chiropractor. I understand that analysis, diagnosis or treatment of me by Chiropractor

may be conditioned upon my consent as evidenced by my signature below.

I understand I have the right to request a restriction as to how my protected health information is used or

disclosed to carry out treatment, payment or healthcare operations of the practice. Chiropractor is not required

to agree to the restrictions that I may request. However, if Chiropractor agrees to a restriction that I request, the

restriction is binding on Chiropractor.

I have the right to revoke this consent, in writing, at any time, except to the extent that Chiropractor has taken

action in reliance on this Consent.

My "protected health information" means health information, including my demographic information,

collected from me and created or received by my physician, another health care provider, a health plan, my

employer or a health care clearinghouse. This protected health information relates to my past, present or future

physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information

may identify me.

I have been provided with a copy of the Notice of Privacy Practices of Chiropractor and understand that

I have a right that Notice 's Notice of Privacy Practices prior to signing this document (notice of privacy

practices is posted on wall by the entrance). 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 my bills or in the

performance of health care operations of Chiropractor. The Notice of Privacy Practices for Chiropractor is also

posted in the waiting room at Fountain Chiropractic. This Notice of Privacy Practices also describes my rights

and duties of the Chiropractor with respect to my protected health information.

Chiropractor 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 of Chiropractor and requesting

a revised copy be sent in the mail or asking for one at the time of my next appointment.

______________________________________

____________________________________

Signature of Patient or Personal Representative

Printed Name of Patient

________________________________

Date of Signing

Patient Financial Responsibility Form Page 2