Chiropractic Patient Intake

Notice of Privacy Practices

This form authorizes Dr. Jon Sheridan, DC (The STRONG Clinic) to collect and maintain your protected health information (PHI) as necessary for the provision of chiropractic care. Your health information may be used and disclosed for treatment purposes, billing (if applicable), and healthcare operations.

You have the right to: receive a copy of this notice, request restrictions on use of your PHI, inspect and copy your health record, and file a complaint if you believe your privacy rights have been violated.

Your information will not be sold or disclosed to third parties for marketing purposes. Electronic records are maintained securely and accessible only to authorized personnel.

By signing below, you acknowledge receipt of this notice and consent to the collection and use of your health information for the purposes described above.

Full Name (as electronic signature) *

Today's Date *

I have read and acknowledge the Notice of Privacy Practices above *

RECEIVED.