We will use your information to respond to you, regarding the reason you contacted us. We will not share your information with any third party outside of our organization, other than as necessary to fulfill your request, e.g. to schedule an appointment.
1. HUG CHIROPRACTIC CLINIC’s (HCC) Privacy Notice has herein been provided to me. The Privacy Notice includes a complete description of the use and/or disclosure(s) of my protected health information (PHI) necessary for HCC to provide treatment to me, and also necessary for HCC to obtain payment for that treatment and to carry out health care operations. I understand that the PRIVACY NOTICE will be available to me in the future at my request. I understand that it is my right to obtain a copy of the Privacy Notice prior to signing this Consent, and I have been encouraged to read the PRIVACY NOTICE carefully prior to my signing this CONSENT.
3. I understand that, and consent to, the following appointment reminders or communications that will be used by HCC:
Telephoning my home and/or office and leaving a message on my answering machine or with the individual who answers birthday, thank you, and/or sentiment cards, other health-related benefits or services that may be of interest to me and patient information publications through hardcopy or electronic media
4. HCC may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for HCC to treat me and obtain payment for that treatment, and as necessary for HCC to conduct its specific health care operations.
5. I understand that I have a right to request that HCC restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or health care operations. However, HCC is not required to agree to any restrictions that I have requested. If HCC agrees to a requested restriction, then the restriction is binding on HCC.
6. I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that HCC has already taken action in reliance on this consent.