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Please discuss any questions or concerns with the Chiropractor, Physical Therapist, Occupational
Therapist, Acupuncturist, Medical Doctor, Surgeon, Nutritionist or Massage Therapist with whom
you will treat before signing this consent.
I hereby give my consent to the provision of care to me or the patient named below, which is
deemed by the appropriate personnel to be necessary and suitable in the diagnosis or treatment of my or the patient’s physical condition. I consent to the performance of chiropractic
adjustments/procedures, physical therapy, occupational therapy, acupuncture, nutrition recommendation and massage therapy as needed.
I have had the opportunity to discuss with the doctor and/or other clinical personnel the benefits of the procedures and other treatments outlined below. Alternatives to treatment have been reviewed.
Chiropractic Care: Though chiropractic adjustments and treatments are usually beneficial and seldom cause any problems, I understand and am fully aware that there are some risks to treatment. Risks include, but are not limited to, fractures, disk injuries, strokes, dislocations, and sprains. I understand that chiropractic/physical therapy/occupational therapy/acupuncture/medical care/massage therapy is not an exact science and therefore, medical practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the chiropractic/physical therapy/occupational therapy/acupuncture/medical care/massage therapy treatment that I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I irrevocably consent to the proposed treatment.
Consent: I have been informed by my physician of the risks and benefits attendant to the course of treatment and/or therapy (hereinafter “treatment”) prescribed by my physician. I understand that it is the opinion of the physician responsible for my care that the benefits of this treatment outweigh the risks of treatment. I fully understand the nature of these risks, including, but not limited to deterioration of my condition, re-injury and/or new injuries. After careful consideration of these risks and benefits, I hereby CONSENT to allow AMG Orthopedics and all personnel employed/contracted by AMG Orthopedics (hereinafter, collectively “AMG”) to perform thetreatment and/or therapy specified by my physician, and deemed necessary and/or advisable by AMG, in accordance with my physician’s orders and standards of good clinical practice. I acknowledge that no promises or representations have been made to me regarding the outcome of this treatment. Despite precautions, I understand that AMG employees may accidentally come into contact with my blood or other bodily fluids as a result of providing the treatment. In cases of such exposure, I agree that my blood may be tested to determine if I have been exposed to certain infectious diseases. The test results will only be used/disclosed as provided for by law. I agree that the results may be used for the diagnosis and/or treatment of the AMG employee(s) that were exposed. Accuracy of documentation is of the highest importance therefore office notes will be available for request 30 days after visit due to internal auditing.
By signing here I acknowledge and agree that I have read, fully understood, and agree to be bound by the terms contained in the Informed Consent. I have been permitted to ask questions about the above-mentioned forms and that any questions have been satisfactorily answered.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information: Please review it carefully.This notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographics that may identify you and that relates to your past, present, and future physical and medical health or conditions that relate to health care services.We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time.The new notice will be effective for all protected health information we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting that revised copy be sent to you in the mail or asking one at the time of your next appointment.
Uses and Disclosures of Protected Health Information:
Uses and disclosures of Protected Health Information based upon your written consent:You will be asked by your chiropractor/physical therapist/acupuncturist to sign consent form(s). Once you have consented to use and disclosure of your protected health information for treatment, payment of health care operations by signing the consent form. Your chiropractor/physical therapist/acupuncturist will use or disclose your protected health information as described in this section. Your protected health information may be used and disclosed by your chiropractor/physical therapist/acupuncturist, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the physician’s office.
We may use or disclose, as needed, your protected health information in order to support the business
activities of your physician’s practice. These activities include, but are not limited to, quality or assessment
activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, and conduction or arranging for other business activities. For example, we may disclose your protected health information to chiropractic/physical therapy/acupuncturist students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your chiropractic/physical therapist/acupuncturist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you for your appointment. We will share your protected health information with third party “Business Associates” that perform various activities (e.g. billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains items that will protect the privacy of your protected health information.We may use or disclose your protected health information as necessary to provide you with information about your treatment alternatives or other health related benefits and services that may be of interest to you. We may also use and disclose your protected health information for chiropractor/physical therapist/acupuncturist marketing activities. For example, your name and address may be used to send you a newsletter about our practice
and the service we offer. We may also send information about products or services that we believe may be
beneficial to you. You may contact our office to request that these materials not be sent to you. We may use
or disclose your demographic information and the dates that you received treatment from your
chiropractor/physical therapist/acupuncturist, as necessary, in order to contact you for fundraising activities
supported by our office. If you do not want to receive these materials, please contact our office and request
that these fundraising materials not be sent to you.
Following are some types of uses and disclosures of your protected health care information that the office is permitted to make once you have signed consent forms.Treatment, Payment, and Healthcare Operations, Others involved in your Healthcare, Emergencies, Communication Barriers:Other permitted and required uses and disclosures that may be without your consent, authorization, or opportunity to object, we may use or disclose your protected health information in the following situations without your consent or authorization includes:Required by Law, Public Health, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donations, Research, Criminal Activity, Military Activity, National Security, Worker’s Compensation, and Inmates.Required uses and disclosures under the law, we must make disclosures to you and when required by the secretary of the Department of Health and Human Services to investigate or determine our
compliance with the requirements of Section 164.500 et. Seq.
You have the right to inspect and copy your protected health information. This means you inspect and obtain a copy of your protected health information about you that is contained in a designated record set for as long as we maintain the protected chiropractor/physical therapist/acupuncturist and the practice uses for making decisions about you. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, of use in, civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances; you may have this decision reviewed. Please contact our office if you have any questions about access to your medical records. You have the right to request a restriction of your health information. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You may have the right to have your chiropractor/physical therapist/acupuncturist amend your protected health information. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. You have the right to obtain a paper copy of this notice form from us upon request. You have the right to complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.You may file a complaint with us by notifying our office of your complaint. We will not retaliate against your for filing a complaint. CONSENT TO USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTH OPERATIONS I understand that as a part of my healthcare, this organization originates and maintains records describing my health history, symptoms, examination and test results, diagnoses, treatment, and plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment A means of communication among the many health professionals who contribute to my care A source of information for applying my diagnosis surgical information to my bill A means by which a third-party payer can verify that services billed were actually provided A tool for routine healthcare operations such as assessing quality and reviewing the competence of professionals.
I understand and have been provided with Notice of Information Practices that provides a more complete description of information and disclosures. I understand I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to object to the use of my health information for directory purposes.I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested.I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I request the following restrictions to the use of disclosure of any health information. I consent to the use and disclosure of my health information for treatment, payment, and healthcare operations as described in the notice of information practices.
I hereby acknowledge that I have received, read, and had an opportunity to ask questions
concerning the All Be Healthy LLC DBA “AMG Orthopedics” NOTICE OF PRIVACY PRACTICE
POLICIES AND PROCEDURES. All Be Healthy may discuss my treatment with the following
people. (include any family, friends, or other contacts.
All Be Healthy LLC d/b/a AMG Orthopedics ("Company" or "Us") seeks your consent to contact you (either directly, through service providers, and/or affiliates) with certain non-emergency, automated, autodialed, prerecorded, or other telemarketing phone calls and or text messages (SMS and MMS) under the Telephone Consumer Protection Act (TCPA). By signing this form, you authorize Us, our service providers, and our affiliates to contact you using:
● The phone and/or mobile number(s) listed below.
● An automatic telephone dialing system (ATDS) or artificial pre recorded voice.
PLEASE NOTE WE WILL NOT SELL YOUR CONTACT INFORMATION AND THIS CONSENT DOES NOT ALLOW THIRD-PARTIES TO CONTACT YOU ABOUT THEIR PRODUCTS OR SERVICES.
ADDITIONALLY, PLEASE NOTE THAT THIS CONSENT ALLOWS US TO CONTACT YOU EVEN IF YOUR PHONE NUMBER IS CURRENTLY REGISTERED, OR IF IT IS LATER REGISTERED, ON ANY STATE AND/OR NATIONAL DO NOT CALL LIST.
I understand that:
● I am not required to grant consent as a condition of buying or obtaining any property, goods, or services.
● I may revoke my consent at any time by emailing email@example.com.
● Message and data rates may apply.
● If my contact information changes, I should inform the Company by emailing firstname.lastname@example.org.