HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED ANDDISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION.
We are required by law to have your written consent before we use or disclose to others your medical information for the purposes of providing or arranging for your health care, the payment for or reimbursement of the care that we provide to you, and related administrative activities supporting your treatment.
We may be required or permitted by certain laws to use and disclose your medical information for other purposes without your consent or authorization.
As our patient, you have important rights relating to inspecting and copying your medical information that we may maintain, amending or correcting that information, obtaining an accounting of our disclosures of your medical information, requesting that we communicate with you confidentially, requesting that we restrict certain uses and disclosures of your health information, and complaining if you think your rights have been violated.
We have available a detailed Notice of Privacy Practice which fully explains your rights and our obligations under the law. We may revise our Notice from time to time. The effective date at the top right hand side of this page indicates the date of the most current Notice in effect.
You have the right to receive a copy of our most current Notice in effect. If you have not yet received a copy of our current Notice, please ask at the front desk and we will provide you with a copy.
If you have any questions, concerns or complaints about the Notice or your medical information please contact Back in Line Health Care 360-977-3532
I understand that diagnosis or treatment of me by Back in Line Health Care may be conditioned upon my consent as evidenced by my signature on this document.
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 health care operations of the practice. Back in Line Health Care is not required to agree to the restrictions that I may request. However, If Back in Line Health Care agrees to a restriction that I request, the restriction is binding.
I have the right to revoke this consent, in writing, at any time, except to the extent that Back in Line Health Care has taken action in reliance on this consent.
My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, Aaron Herbert, DC., a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I understand I have a right to review Back in Line Health Care’s Notice of Privacy Practices prior to signing this document.
The Back in Line Health Care’s Notice of Privacy Practices has been provided to me.
The Notice of Privacy Practices described the type 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 Back in Line Health Care.
This Notice of Privacy Practices also describes my rights and the duties of Aaron Herbert, DC. with respect to my protected health information.
Aaron Herbert, DC. reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.
I may obtain a revised notice of privacy practices by calling Back in Line Health Care (Aaron Herbert, DC) and requesting a revised copy be sent via email, mail or asking for one at my next appointment.
The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual. Healthcare entities must keep records of PHI disclosures.
Chiropractic care is the science, philosophy and art of locating and correcting spinal subluxations (misalignments) and, as such is oriented toward improvement of spinal function relative to range-of-motion, muscular and neurological aspects. Extremities may also be treated as related to spinal function. There has been no promise, implied or otherwise, of a cure for any symptom, disease or condition as a result of treatment at this clinic.
I understand that the chiropractor will use his hands or a mechanical device upon my body to locate and treat involved areas. He may apply pressure on certain spots in my muscles to the point I can tolerate. I am to communicate with the doctor at all times to let him know if any procedure is painful or in any way uncomfortable for me.
It is my intention to rely on the doctor to exercise professional judgment during the course of any procedures, which he feels at the time to be in my best interest.
Neither the practice of chiropractic nor medicine is an exact science, but relies upon information related by the patient, information gathered during the examination, and the doctor's interpretation thereof, as well as the doctors’ judgment and expertise in working with like cases.
It is not reasonable to expect the doctor to be able to anticipate, or explain, all possible risks and complications of a given procedure on any particular visit. I understand that if I have questions or concerns, I must ask.
An undesirable result or side effect does not necessarily indicate an error in judgment or an improper procedure. The doctor may recommend altering my activities of daily living and/or recommend further diagnostic testing or medical referral. Noncompliance with the doctor's recommendations could be detrimental to my health.
As with any health care procedure, there are certain complications that may arise during chiropractic treatment. Those complications include burns, sprains/strains, dislocations, fractures, disc injuries, or cerebral-vascular accidents (strokes). These complications are rare occurrences.
Some very effective chiropractic soft tissue treatment techniques require exposure of the skin in the areas being treated. A proper gown and/or cover up will always be provided. However, due to individual levels of personal modesty, if you feel at all uncomfortable, please immediately tell the doctor or assistant. A different treatment technique will be used.
Generally chiropractic treatment is a safe and cost effective conservative treatment for many musculoskeletal conditions and has a documented high level of patient satisfaction toward treatment and outcome. However, there are other treatment options available to you such as medical, drugs and sometimes surgery.
I have read the above consent, or have had it read to me, and have had the opportunity to ask questions and receive answers. I am comfortable with the information provided and consent to chiropractic treatment and management on that basis.