Any personal information you provide to us on our website (i.e. name, address, e-mail address, telephone number and credit card information) is maintained in private files on our secure Web server and our internal systems. Your personal information will not be shared with anyone. We will not sell, rent or share your e-mail address with others for them to send you unsolicited e-mail.
CONSENT FOR PURPOSES OF TREATMENT, PAYMENT AND
I acknowledge that Total Health Chiropractic Center’s “Notice of Privacy Practices” published April 14, 2003 has been provided to me.
I understand I have a right to review Total Health Chiropractic Center’s Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types 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 Total Health Chiropractic Center.
The Notice of Privacy Practices for Total Health Chiropractic Center is also provided on request at the main administration desk of this practice. This Notice of Privacy Practices also describes my rights and Total Health Chiropractic Center’s duties with respect to my protected health information.
Total Health Chiropractic Center reserves the right to change the privacy practices that are described in the Notice of Privacy Practice. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail, ask for one at the time of my next appointment or accessing Total Health Chiropractic Center’s website (if applicable).
I have the right to revoke this consent, in writing, except to the extent that Total Health Chiropractic Center has taken action in reliance on this consent.