RESTRICTIONS ON USE
THE SYSTEMS SURVEY IS TO BE USED ONLY BY TRAINED HEALTH CARE PRACTITIONERS.
IF YOU ARE A PATIENT, YOU SHOULD NOT USE THE SYSTEMS SURVEY. IF YOU ARE NOT A TRAINED HEALTH CARE PRACTITIONER, YOU SHOULD NOT USE THE SYSTEMS SURVEY. HEALTH CARE PRACTITIONERS SHOULD ONLY USE THE SYSTEMS SURVEY TO PROVIDE SERVICES THAT ARE WITHIN THE SCOPE OF THEIR LICENSE OR PROFESSIONAL TRAINING. THE SYSTEMS SURVEY IS NOT INTENDED TO DIAGNOSE ANY DISEASE. THE SYSTEMS SURVEY IS INTENDED TO BE USED AS A HELPFUL TOOL FOR HEALTH CARE PRACTITIONERS IN COLLECTING INFORMATION CONCERNING THE HEALTH AND WELLNESS OF PATIENTS.
I authorize the release of all medical records maintained by Bellevue Chiropractic which relate to services I have received from, or the results of tests ordered by, Bellevue Chiropractic. These records may be released as needed for my care, for the processing of insurance claims, to satisfy the requirements of a managed care organization of which I am a member, and/or to my attorney regarding pending or anticipated litigation under a worker’s compensation, motor vehicle accident, and/or third party liability claim.
I authorize direct payment of benefits from my insurance plan to Bellevue Chiropractic. I understand that I am responsible for payment of professional fees charged by Bellevue Chiropractic which are not covered, or not properly reimbursed, under the terms of my insurance plan.
I will provide Bellevue Chiropractic with the phone numbers I authorize Bellevue Chiropractic to use to contact me. I authorize the use of any messaging person or system, voice mail and/or an answering machine to convey information regarding my care.
I authorize the use of Faxing or Email to send my information to myself or to other parties that have a right to receive my information. I understand that every effort is made to protect my privacy, however, no absolute privacy guarantee is given when faxing or Email is used.
This notice is effective as of the date this is submitted. This notice will expire seven years after the date upon which the record was created. By signing below, I acknowledge that I have received a copy of this notice.