Patient Authorization regarding chiropractic care being provided in an “open adjusting” environment: It is the practice of this office to provide chiropractic care in an “open adjusting” environment. “Open adjusting” means that while you are the only patient in an exam room, the door is usually open during your adjustment. Periodically patients are within sight of one another and some ongoing routine details of care are discussed within earshot of other patients and staff. This environment is used for ongoing care, NOT for taking patient histories, performing examinations or presenting reports of findings. These procedures are completed in a private, confidential setting. We are requesting this authorization of you due to various interpretations under federal law with respect to what is known as “incidental disclosures” of health information. It is our view that the kind of matters related in an “open adjusting” environment are incidental matters. In the event you or someone else would not agree with us, we are providing this disclosure. The use of this format is intended to make your experience with our office more efficient and productive as well as enhance your access to quality health care and health information. If you choose not to be adjusted in an open adjusting environment other arrangements will be made for you. Your decision will have no adverse effect on your care from Jernigan Chiropractic Clinic or on your relationship with our staff. Your signature indicates your authorization of this activity.
It is our desire for our staff to use your name, address and/or telephone number for the purposes of contacting you to remind or advise you about: Appointment related issues, insurance correspondence and billing, and mailings from our office. The use of this information is intended to make your experience with our office more efficient and productive. If you choose not to authorize this decision will have no adverse effect on your care from Jernigan Chiropractic Clinic or on your relationship with our staff.
You may revoke this authorization at any time. Revocation may be accomplished by advising us in writing of your desire to withdraw your authorization. Please allow a reasonable processing time for the changes in our system to be completed.