I hereby state that by signing the consent, I acknowledge and agree as follow.*

1. The Practice’s privacy Notice has been provided to me prior to my signing the consent. The privacy Notice includes a complete description of the uses and/or disclosure of my protected health information (“PHI”) necessary for the Practice to the treatment to me, and also necessary to the practice to obtain payment for the treatment and to carry out its health care operations. The Practice explains to me that privacy notice will be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the Privacy Notice to signing this Consent, and has encouraged me to read the Privacy Notice carefully prior to my signing the consent.
2. The Practice reserves the right to change these privacy practices that are described in its Privacy Notice, in accordance with the applicable law.
3. I understand that, and consent to, the following appointment reminders will be used by the practice: a) a postcard mailed to me at the address provide by me b) emailing c)texting d) telephoning my home and/or cell phone, leaving a message, with individual answering the phone.
4. The Practice may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the Practice to treat me and obtain payment for that treatment, and as necessary for the Practice to conduct its specific healthcare operations.
5. I understand that I have the right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or healthcare operations. However, the Practice is not required to agree to any restrictions that I have requested. However, if the practice agrees to a requested restriction, then the restriction is building on practice.
6. I understand that this consent is valid until authorization is revoked or when minor becomes of legal age. I further understand that I have the right to revoke this Consent, in writing at any time for all future transition, with the understanding that any such revocation will not apply to the extent that the Practice has already taken action in reliance on this consent.
7. I understand that if I revoke this Consent at any time, the Practice has the right to refuse to treat me.
8. I understand that if I do not sign this Consent evidencing my consent to the uses and disclosure described to me above the contained in the Privacy Notice, then the Practice will not treat me.
9. I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that can understand.

1. I hereby authorize Faulkenberry chiropractic to use and/or disclose to my insurance company, billing company stuff, other insurance companies, past and present employers if applicable, my attorney and other attorneys, medical doctors, medical testing facilities and other health care professionals or to (if not already covered above) that have interest in my health care, following specific protected health information. Office note, medical reports, test results, disability status, billing information, visit dates, insurance information and any other health information that have occurred at this office and/or obtained from other health care facilities by this office.
2. I understand that this authorization is valid for until revoke authorization or until minor becomes of legal age.
3. I understand that the purpose or use of this disclosure I am granting is to enable this office to communicate my health status to the above-mentioned professions and people.
4. I expressly acknowledge that this authorization is voluntary.
5. The following is/are other criteria or limitations that I make regarding this authorization:
6. I understand that the office/practice will not receive financial or in-kind compensation in exchange for using or disclosing the health information described above with the exception of the normal reasonable and customary copy fee if applicable.
7. I understand that this authorization may be revoked by me and the authorizer at any time. Provided the revocation is in writing and revokes this refers to this specific dated authorization of which I will receive a copy. However, I also understand that the revocation of this particular authorization will not have any effect on disclosures occurring prior to the execution of any revocation.
8. I understand that the information used or disclosed pursuant to this authorization may be subject to being disclosed again by the recipient and this information will no longer be protected by the federal privacy regulations.
9. I understand that my health care and payment for my health care will not be affected if I do not sign this form.
10. I understand that I may see and copy the information described in this form, if I ask for it, that I will get a copy of this form after I sign it upon my request.
11. I understand that I may refuse to sign the authorization form.
12. This form was completely filled in before I sign it. I certify that all questions were answered to my satisfaction and that I understand this authorization form and all of its contents.
13. This authorization is valid as of the date I sighed below.

I, {name679}, hereby consent to allow the following persons access to information on my account that would otherwise be considered Protected Health Information.

FINANCIAL POLICY

It is the policy of Faulkenberry Chiropractic, to collect payment in full at the time services are rendered. Prior to, or at the time services are rendered, we will quote you your financial responsibility based on your individual insurance coverage.

While we make every attempt to be as accurate as possible, you may have a balance or credit due, depending on the service provided, and/or the adjudication process with your insurance carrier. We accept cash, check and most major credit cards. We also accept Care Credit for your convenience.

In the case of an Auto Accident we will file a Medical Lien to the 3rd party insurance to insure payment for serves rendered

There will be a $10.00 fee added to your account if you miss any appointments and fail to call 12 hours prior, after 3 no call/no show you will be charged a $50 fee.

Thanks again for choosing Faulkenberry Chiropractic for your Chiropractic needs. We look forward to serving you.

I understand the above information and will be responsible for the patient list below:

Assignment and release

I Certify that I, and/or my dependent(s), have insurance coverage with {insuranceCompanyies} and assign directly to

Dr Faulkenberry all insurance benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for all changes whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed.