CONSENT TO TREAT: Chiropractic is a non-surgical, non-invasive procedure and has one of the safest records in health care. As with any health care specialty, we cannot promise a cure but we will give you our best care and we will discuss any questions or concerns with you.
Patients may experience temporary symptoms such as an increase in soreness following a massage, manipulation, or traction. In addition, physiotherapy such as ice, heat, or ultrasound may irritate the skin. There have been a few cases where chiropractic adjustments have aggravated a bulging or herniated disc or caused a rib fracture. On extremely rare occasions, adjustments to certain areas of the cervical spine have been related to a compromise of the vertebral artery and possible stroke symptomatology.
I acknowledge that I have discussed non-surgical chiropractic care and physiological therapeutics and I authorize Syracuse Chiropractic Center, P.C. to perform such care.
AGREEMENT OF INSURANCE BENEFITS: I assign to Syracuse Chiropractic Center all insurance benefits to which I may be entitled for the charges owed to Syracuse Chiropractic Center. The assignment includes, but is not limited to, major medical and disability insurance, and the proceeds of any settlement, or judgement awarded for personal injuries caused by a third party. I hereby authorize direct payment to all such insurance benefits to Syracuse Chiropractic Center and I agree to pay for any and all charges not paid in pursuant to this agreement.
ACKNOWLEDGMENT RECEIPT: HIPAA NOTICE OF PRIVACY PRACTICES:
In signing this form, you agree that you have received our Notice of Privacy Practices. This Notice, among other points, explains how we plan to use and disclose your protected health information for the purposes of treatment, payment and health care operations. This applies to the privacy practices of Syracuse Chiropractic Center and all affiliated covered entities of Syracuse Chiropractic Center issuing this Notice.
You have the right to review our Notice of Privacy Practices prior to signing this form. It provides more detail on how we may use and disclose your information. The Notice of Privacy Practices may change. A current copy may be requested by contacting our Chief Privacy Officer at 402-269-3130.
By signing this form, you acknowledge you have received our Notice of Privacy Practices and that Syracuse Chiropractic Center and all affiliated covered entities can use and disclose your protected health information in accordance with HIPAA.
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Patient/Person Authorized to Consent
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Witness