MEDICAL RECORDS/IMAGING: I authorize the release of any and all information/records/x-rays, etc. need to evaluate my condition. I further request that this and any other pertinent information be forwarded to PLUS CARE CHIROPRACTIC & WELLNESS, 1809 E 10th St, Jeffersonville, IN 47130, Fax: 812-280-5253.

REQUEST FOR MEDICAL CARE: I voluntarily consent to examination, lab evaluation, treatment and the rendering of care, including physical therapy treatments, massage therapy and manipulations. I grant my consent for treatment for myself, my spouse, or my minor children/dependent as listed on this form.

RELEASE OF CREDIT INFORMATION: When applying for a Care Credit card, I hereby authorize PLUS CARE CHIROPRACTIC &

WELLNESS and/or its assign all rights necessary to obtain financial information on me or my spouse in order to make determination of my credit worthiness. Additionally, I authorize PLUS CARE CHIROPRACTIC & WELLNESS and or its assigns to obtain a pre-approval for credit on services or treatments that may or may not be utilized in our office

As required by the Privacy Regulations, I am aware that Plus Care Chiropractic has included a provision that it reserves the right to change the terms of its notice and to make the new notice provisions effective for all protected health information that it maintains.

Requests:

- I wish to file a “Request for Restriction” of my Protected Health Information

- I wish to file a “Request for Alternative Communications” of my Protected Health Information

- I wish to object to the following in the “Notice of Privacy Practices:”

I understand that this office is not required to honor any changes to the “Notice of Privacy Practices.”