Chiro Child Intake Form (Page 4 of 4) in pdf

2503 Walnut St #100, Boulder, Colorado 80302

Phone: (303) 578-0771

Consent for Purpose of Treatment and Healthcare Operations

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

I consent to the use or disclosure of my protected health information by Integrative Health for the pur-

pose of analyzing, diagnosing and providing treatment to me, obtaining payment for my health care bills

or to conduct health care operations. I understand that analysis, diagnosis or treatment of me by Life-

time Wellness of Boulder 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, Lifetime Wellness

of Boulder is not required to agree to the restrictions that I may request. However, if Lifetime Wellness

of Boulder agrees to a restriction that I request, the restriction is binding on Lifetime Wellness of Boul-

der. I have the right to revoke this consent, in writing at any time, except to the extent that Lifetime

Wellness of Boulder has taken action in the reliance on the 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, health plan,

my employer or a health care clearing house. This protected health information relates to my past, pre-

sent or future physical or mental health condition and identifies me, or there is a reasonable basis to be-

lieve the information may identify me.

I may obtain a copy of the HIPAA Notice of Privacy Practices of Integrative Health and understand that I

have the right to read that Notice of Privacy Practices prior to signing this document. The Notice of Pri-

vacy 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 Lifetime

Wellness of Boulder, as well as my rights and duties of Lifetime Wellness of Boulder with respect to my

protected health information. The Notice of Privacy Practices for Lifetime Wellness of Boulder is located

in our waiting room.

___________________________________________________________________

Your Printed Name

____________________________________________________

______________

Signature

Date

_____________________________________________________

Parent signature if patient is a minor

Chiro Child Intake Form Page 4