HIPPA Form

Patient's Name

Patient's Social Security Number

LEGAL RESPONSIBILITY: LEGAL RESPONSIBILITY: I am 18 years old or older and am legally responsible for myself. I am an emancipated child or teenager and my parents no longer have custody over me. I am a child or teenager and my parents are divorced.

Parent or Guardian Name(s):

USE AND/OR DISCLOSURE: USE AND/OR DISCLOSURE: I understand that under HIPAA regulations, my health information will be used and disclosed to any health care provider who is involved with my medical treatment of services, my health insurance plan, and any medical billing cleaning house who is involved with your insurance claims fulfillment. Under these new regulations the following people must be authorized by you to have access to your health information your spouse, other family members, and friends; nurse or home aid; legal guardian or other person/organization who is not involved with your medical treatment, insurance plan, or payment.

AUTHORIZATION: AUTHORIZATION: Please list the people or organizations that you authorize to have access to your information:

Emergency Contact Name:

Emergency Contact Phone Number:

Emergency Contact Address

Relationship to Patient:

What specific information to disclose?

What date will the disclose expire?

CHANGING YOUR MIND CHANGING YOUR MIND I understand that I may revoke this authorization at any time by giving written notice to your Privacy Officer.

METHOD OF CONTACT - I authorize the office of Carlisle Chiropractic Clinic to contact me in the following manner (Select all that apply): METHOD OF CONTACT - I authorize the office of Carlisle Chiropractic Clinic to contact me in the following manner (Select all that apply): Home telephone Written mail Leave a message with detailed information Call my work Email me Leave a message with a call back number only

STATEMENT OF UNDERSTANDING: STATEMENT OF UNDERSTANDING: I have reviewed and I understand this Authorization. I also understand that my health information will be used or disclosed to certain business associates of Carlisle Chiropractic Clinic who are part of the healthcare process. These business associates will also keep your health information confidential.