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NOTICE OF PRIVACY PRACTICES
This notice describes how and why your health information may be used and how you can gain access to this information. Please review the information carefully.
(If there are any areas which you might need more clarification on please do not hesitate to ask.)
The most significant variable which motivated the Federal government to legally enforce the privacy of health information is the rapid evolution of electronic technology in the health care business. The government has sought to standardize and protect the electronic exchange of your health information. This has challenged us to review how your information is used within our computers, on the Internet, as well as phones, fax machines, and any device used to copy or transfer patient data. We want to advise you that we have developed policies and procedures for our practice to insure your personal health information will be shared only as required for the purpose of administering your care. Our office is subject to State and Federal laws regarding the confidentiality of your health information. We also want you to understand our procedures and your rights as a valued patient. Your health information will be communicated only for the purpose of conducting health care business. Be assured that without your written permission, your health information will not be used for any other purpose.
Why Your Health Information May Be Used To Provide Treatment:
Within our office, your health information will be used to provide you the best care and services possible. This may include administrative and clinical procedures designed to optimize scheduling and coordination between you and office personnel. In addition, we may share this information with referring physicians, clinical radiological laboratories, or other health professionals providing treatment. Here are some of the reasons we may need to share information.
Because we believe your health goals are very important to your overall care and treatment plan, we will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may be of interest to you and your family. These communications are an important part of our philosophy, which is to partner with our patients to see they receive the best chiropractic care we can provide. This may include postcards, newsletters, flyers, and telephone or electronic reminders such as e-mail. (Please tell us if you prefer not to receive these types of reminders or notifications).
Your health information may be included with an invoice in order to collect payment for the services provided to you in this office. We may do this with insurance forms filed for you electronically or by mail. We will make every effort to work with companies with a similar commitment to the security of your health information.
We may be required to disclose necessary health information to Federal officials or military authorities in order to complete investigations related to public health and or national security.
As permitted or required by State and Federal law, we may disclose your health information under certain circumstances to proper authorities for the purpose of law enforcement. This may take place if you are a victim of a crime, or in order to report a suspected crime.
We may share your health information with those that assist you with your home hygiene, care, treatment, or payment. We will be certain to obtain your permission prior to sharing your information. In the event of an emergency, if you are unable to communicate your wishes, we will use our very best judgment when sharing your health information with anyone participating in your care.
Other than the information stated above, or information that Federal, State, and Local laws require, we will not disclose your health information without your written authorization.
INFORMED CONSENT TO CHIROPRACTIC CARE
This is an explanation of the chiropractic adjustment, other treatment options, and the risks and benefits of each. The primary treatment used by doctors of chiropractic is the spinal adjustment. I will use that procedure to treat you.
THE NATURE OF THE CHIROPRACTIC ADJUSTMENT - I will use my hands, a mechanical device called an activator, or other chiropractic instruments on your body in such a way as to move your joints. This may cause an audible "pop" or "click" called an audible release. You may feel or sense movement.
THE MATERIAL RISKS INHERENT IN A CHIROPRACTIC ADJUSTMENT AND THE PROBABILITY OF SUCH RISKS OCCURING - As with any health care procedure, there are certain complications that may arise during a chiropractic adjustment. These rare complications include: fracture, disc injuries, dislocations, muscle strain, costovertebral strains and separations. These usually occur when there is underlying pathology.
Fractures are rare occurrences and generally result from some underlying weakness in the bone, which I screen for during the examination.
Some types of spinal manipulations of the neck have been associated with injuries to the arteries in the neck, leading to or contributing to serious complications, including stroke. The probability of stroke has been the subject of disagreement: One authority states that there is, at most, a one-in-a-million chance of such an outcome. Since even that risk should be avoided, I employ tests during the examination that are designed to identify if you may be at risk.
Other "rare" complications are indeed rare, and low force techniques are utilized, when possible, to help minimize any risk. Some patients will feel some stiffness and soreness following the first few days of treatment.
ADDITIONAL TREATMENTS AVAILABLE IN THIS OFFICE, AND ASSOCIATED RISKS - In addition to chiropractic adjustments, I may use the following treatments. Manual traction or Neuromuscular re-education, this may lead to soreness or headaches if 2-3 glasses of water are not consumed within one hour. Ice treatment may cause frostbite if not used according to instructions. Exercise instruction may lead to muscle strain and/or joint strain if the exercises are not performed correctly as directed.
THE NATURE OF OTHER TREATMENT OPTIONS, WHICH ARE NOT AVAILABLE HERE. THE MATERIAL RISKS INHERENT IN SUCH OPTIONS AND THE PROBABILITY OF SUCH RISKS OCCURRING - Self-administered care such as over-the-counter analgesics and bed rest have large risks. Long-term uses of over-the-counter medicines produce undesirable effects, which include (but are not limited to) kidney failure, as described in current medical literature. For some risks associated with bed rest, see "Risks And Dangers of Remaining Untreated".
Medical care with prescription drugs such as anti-inflammatory, muscle relaxants and painkillers do have significant risks. Overuse of prescription muscle relaxants and painkillers produce undesirable side effects and patient dependence. The risks of such complications arising are dependent upon the patient's general health, severity of the patients discomfort, pain tolerance, self-discipline (in not abusing the medicine), and proper professional supervision. Medications generally cause significant risks often with rather high probabilities of occurrence.
Hospitalization with traction bears additional risks of exposure to communicable disease, iatrogenic mishap (doctor induced illness), and enormous monetary expense. The probability of iatrogenic mishap is infrequent, and exposure to communicable disease likely, but both events are dependent upon unknown variables. The risk of great monetary expense is certain.
The risks inherent in surgery include adverse reaction to anesthesia, risk of iatrogenic mishap, and all the risks stated above for hospitalization, plus an extended convalescent period.
THE RISKS AND DANGERS OF REMAINING UNTREATED - Remaining untreated allows the formation of adhesions (internal scar tissue) in the spine and associated muscles and ligaments. This reduces mobility, which then sets up a pain reaction, further limiting the range of motion and restricting normal activities of daily living in work and play, and may lead to degeneration of the spine. The probability that non-treatment will complicate a later rehabilitation is very high.
DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTOOD THE ABOVE
I have read the above explanations of risk. I have had my questions answered to my satisfaction. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo chiropractic care. Having been informed of the risks, I hereby give my consent to chiropractic treatment.
Thank you for choosing us as your primary care provider. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.
Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area.
Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.