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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, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as a cervical arterial dissection that involves an abnormal change in the wall of an artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. This occurs 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. As chiropractic can involve manually and/or mechanically adjusting the cervical spine, it has been reported that chiropractic care may be a risk for developing this type of stroke. The association with stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments.
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: Billing Information My account will be: Insurance Self Pay If Insurance:
INSURANCE ASSIGNMENT AND RELEASE
I, the undersigned certify that I (or my dependent) have insurance coverage and assign directly to Dr. Scoles 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.
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. I consent to chiropractic spinal x-rays.
I agree to pay an additional $30 in the event that the doctors decide a second opinion is necessary and send my radiographs to a chiropractic radiologist for a second opinion.
X-ray Consent Signature Pregnancy Release:
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