Privacy Notice Acknowledgement
I, ______________________________, hereby acknowledge that I have been given the opportunity to receive a copy of this practice’s Notice of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this Notice.
I also authorize Back to Health Family Chiropractic, PC to release any and all information concerning my treatment to insurance carriers, referring doctors, lawyers, and other providers involved in my care for the purpose of my treatment, payment for services rendered or daily operations involved in my care.
Signature of Patient or Parent/Legal Date
Guardian if patient is a minor child
Patient Name (if minor child)
Please list anyone other than those listed above that we are permitted to speak with regarding your care
I wish to be contacted in the following manner (check all that apply):
□ Home Telephone: __________________ □ Written Communication: _____________
□ O.K. to leave message with detailed □ O.K. to mail to my home address
information □ O.K. to mail to my work/office address
□ Leave message with call-back □ O.K. to fax to this number
□ Work Telephone _____________ □ Other: ____________________________
□ O.K. to leave message with detailed ______________________________
□ Leave message with call-back ________________________________