Practice Member Health Information Consent Form

 

Before we begin any health care services, we require you to read and sign this consent form stating you understand and agree how your records will be used.

1.  The practice member understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of the chiropractic and acupuncture methods I use for health care operations and coordination of care.

2. The Practice member has a right to obtain a copy of her/his own health records at any time.

3. The practice member’s written consent need only be obtained one time for all subsequent care given in this office.

4. I have taken all precautions to assure your records are not readily available to those who do not need them.

5. The chiropractic and acupuncture methods I use sometimes require that I touch the tailbone (coccyx), the lower back(sacrum), lower abdomen and the chest area. Is it ok if I touch you there for purposes of doing CSFI and acupuncture?    Yes     No

The practice of Chiropractic/Acupuncture is regulated by the Director of Regulations, Colorado Department of Regulatory Agencies (DORA). If you have questions, comments or complaints, you can contact the Chiropractic Board – 303-894-7851

 

Date_________________

Printed Name__________________________________________

Signature______________________________________________

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