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Notice of Privacy Practices Acknowledgement HIPAA Initial Uses Authorization Form
Scoles Family Chiropractic
Effective: April 14, 2003
Initial Acknowledgement and Uses
By signing this form, you acknowledge that you were presented with a copy of the Notice of Privacy Practices of Scoles Family Chiropractic, PLLC. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full. For an online version, please visit:
Our Notice of Privacy Practices is subject to change. The most current Notice of Privacy Practices will be placed on display in the office at all times. You may obtain additional copies of our most current notice by requesting it from our privacy official, Dr. Jennifer Scoles.
If you have any questions regarding this notice or our health information privacy policies, please contact: Dr. Jennifer Scoles
You can reach the Privacy Official at:
Scoles Family Chiropractic, PLLC
7555 Oak Ridge Hwy.
Knoxville, TN 37931
Phone number: 865-531-8025
Hours Available: A message may be left for our privacy official any time the clinic is open and your call will be returned within 7 business days.
HIPAA Signature of Patient/Personal Representative * Relationship if not patient: Informed Consent to Care
You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as “informed consent” and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care.
We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable.
Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.
It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains.
With respect to strokes, there is a rare but serious condition known as an “arterial dissection” that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis.
Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not.
Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke.
The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was
1219 events/ per one million persons/year and risk of death has been estimated as 104 per one million users.
It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.
I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.
Informed Consent Signature * Relationship if not patient: TERMS OF ACCEPTANCE
When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective.
Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.
ADJUSTMENT: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxations. Our chiropractic method of correction is by specific adjustments to the spine.
HEALTH: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.
VERTEBRAL SUBLUXATION: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.
We do not offer to diagnose or treat any disease or condition other than vertebral subluxations. However, if during the course of chiropractic spinal examination, we encounter non-chiropractic or unusual finding, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of another health care provider.
Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.
When you provide us with your contact information, we may use that information to provide you services. For example, we may use your contact information to send you appointment reminders and office updates via text or SMS message. We may use business partners to provide these services to you. If you do not wish to receive these messages, please notify us. But recognize that if you choose not to share the information, we may not be able to provide you with certain services. We will never sell your information.
Terms of Acceptance Signature *
I have read and fully understand the above statements. I therefore accept chiropractic care on this basis.
Billing Information My account will be: Insurance Self Pay If Insurance:
INSURANCE ASSIGNMENT AND RELEASE
I, the undersigned certify that I have insurance coverage and assign directly to Scoles Family Chiropractic all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance.
With my signature, I authorize the release of any information necessary to process my insurance claims. I authorize and request payment of insurance benefits directly to the doctors. I agree that this authorization will cover all services rendered until I revoke the authorization. I agree that a photocopy of this form may be used in place of the original. It is customary to pay for services when rendered unless other arrangements have been made in advance. I understand that I am financially responsible for charges not covered by this assignment.
Insurance Signature If Self Pay:
I understand that I am financially responsible for all charges if I do not have insurance.
Self Pay Signature X-ray Consent:
The purpose of the x-rays about to be taken is to analyze the spine for vertebral subluxations and to determine the appropriateness of chiropractic spinal adjustments. Please note: if X-rays are necessary, they are utilized in this office to help locate and analyze vertebral subluxations. These x-rays are not used to investigate for medical pathology. The doctors of Scoles Family Chiropractic do not diagnose or treat medical conditions; however, if any abnormalities are found, we will bring it to your attention so that you can seek proper medical advice. I consent to chiropractic spinal x-rays. In the event that the doctors decide a second opinion is necessary and send my radiographs to a chiropractic radiologist for a second opinion, I agree to pay for that services which is usually an additional $30 .
X-ray Consent Signature - BY SIGNING BELOW YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS. Pregnancy Release (Female Patients Only)
This is to certify that to the best of my knowledge I am NOT pregnant and the chiropractor and his/her associates have my permission to perform an x-ray evaluation. I understand that x-ray can be hazardous to an unborn child.
Date of last menstrual cycle: Pregnancy Release Signature