Medical Treatment/HIPPA. This form contains how your Patient Health Information (PHI) will be used in our office. By signing at the end of these policies, you agree to all stipulations.

1. The patient has the right to exam and obtain a copy of his/her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.

2.A patient’s written consent need only be obtained on time for all subsequent care given to the patient in this office.

3. The patient may provide a written request to revoke consent at any time during care. This would not affect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented

4. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse care.

5.I hereby request and consent to the performance of joint mobilization, osteopathic or chiropractic manipulation, physiotherapy or other medical procedures including diagnostic x-rays (if necessary) on me or, the patient named below, for whom I am legally responsible, by the doctors and staff at Chiro on Call Pllc.

6. I have had, or will be responsible for having, such discussions with the doctors and staff at Chiro on Call Pllc. that will provide, or has provided me with the opportunity to become fully apprised of the nature and purpose of joint mobilization, osteopathic or chiropractic manipulation, as well as the various physiotherapeutic and medical procedures performed by the doctors and licensed or otherwise qualified staff at Chiro on Call Pllc.

7. I understand and am fully informed that, in the practice of physical medicine, there are risks, including but not limited to, dislocation, fracture, disk injury, stroke, sprains and strains. I do not expect the doctors or staff at Chiro on Call Pllc. to be able to anticipate and explain all the risks and complications potentially inherent in physical medicine, but instead, I wish to rely upon those employed by, or those who work at Chiro on Call Pllc. to exercise good judgment in the prudent application of a course of treatment, prescribed in my best interest and based upon the known facts regarding my condition.

8. I hereby acknowledge that by signing this, I fully understand that Dr. Aleksey Polyakov DC has ownership interest in CHIRO on Call, PLLC and will financially benefit from the procedures and services being performed. Should I elect not to accept, I am hereby informed and understand that I may choose another facility within which I can receive services.

9. I understand that Chiro on Call PLLC is a Concierge Practice, NO INSURANCE OR THIRD-PARTY direct to provider reimbursement are accepted at the current time. You will be given a superbill with itemized charges, if you request it. It can be submitted to a third party for reimbursement.

10. I give permission to the office to send me birthday cards, holiday-related cards, thank you cards and gifts. Call/Text/E-mail me and/or leave me messages for me on an answering machine. Provide me information on treatment and other health related information.

I have read, or have had read to me, the above informed consent and have had the opportunity to ask questions regarding its contents. By signing below, I acknowledge all that is memorialized above and intend that this informed consent cover the entire course of treatment for my current condition and any future conditions for which I may seek care.

The patient understands and agrees to allow CHIRO on CALL to use their PHI for the purpose of treatment, payment, health care operations and coordination of care.

NOTE: If you do not understand any part of this document, please speak to a doctor before signing.

TO BE COMPLETED BY PATIENT or LEGAL REPRESENTATIVE

Patients Name (Print Please) ____________________________________________________________________________

Signature of Patient (Legal Representative) ___________________________________________

Witness ___________________________________________Date Signed_________________

Refund Policy