![]() ![]() This Notice details how your PHI may be used and disclosed to third parties. The creation of a record detailing the care and services you receive helps thisoffice to provide you with quality health care. PLEASE REVIEW IT CAREFULLY.This Practice is committed to maintaining the privacy of your protected health information ("PHI"), which includes information about your healthcondition and the care and treatment you receive from the Practice. #Switching from autumn 8 to chiro touch professional#I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.HIPAA NOTICE OF PRIVACY PRACTICESTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GETACCESS TO THIS INFORMATION. ![]() ![]() I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I consent to the collection and use of the above information to this office of chiropractic. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I certify that I'm the patient or legal guardian listed above. Click on a crayon and draw on the body above to indicate your symptoms Authorization ![]()
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