Patients/Clients are billed 100% for failure to cancel less than 3 hours prior to the scheduled appointment.
Dr Nicol and staff communicate to their patients via email and text messaging, example: appointment reminders, thank you notes, birthday cards and health articles. If you prefer not to receive this communication, please check the appropriate box(s) below.
I acknowledge that I understand the Cancellation Policy and have received the Clinic's Notice of Privacy Practices for protected health information.
Facility Name: Body Integrations Chiropractic
I have been given a copy of Body Integrations Chiropractic's Notice of Privacy Practices ("Notice"), which describes how my health information is used and shared. I understand that Body Integrations Chiropractic has the right to change this Notice at any time. I may obtain a current copy by contacting the Facility Privacy Official, or by visiting the Body Integrations Chiropractic web site at www.awesthoustonchiropractor.
My signature below acknowledges that I have been provided with a copy of the Notice of Privacy Practices:
1. If the patient or personal representative is unable or unwilling to sign this acknowledgement, or the Acknowledgement is not signed for any other reason, state the reason:
2. Describe the steps taken to obtain the patient's (or personal representative's) signature on the Acknowledgement
Completed by:
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
This Facility is required by law to provide you with this Notice so that you will understand how we may use or share your information from your Designated Record Set. The Designated Record Set includes financial and health information referred to in this Notice as "Protected Health Information" ("PHI") or simply "health information." We are required to adhere to the terms outlined in this Notice. If you have any questions about this Notice, please contact Body Integrations Chiropractic at 713-781-3114.
UNDERSTANDING YOUR HEALTH RECORD AND INFORMATION
Each time you are admitted to our Facility, a record of your stay is made containing health and financial information. Typically, this record contains information about your condition, the treatment we provide and payment for the treatment. We may use and/or disclose this information to:
Understanding what is in your record and how your health information is used helps you to:
HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU
The following categories describe the ways that we use and disclose health information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall into one of the categories
OTHER ALLOWABLE USES OF YOUR HEALTH INFORMATION
Public Health Risks. We may disclose health information about you for public health purposes, including:
Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law.These oversight activities may include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Reporting Abuse, Neglect or Domestic Violence: Notifying the appropriate government agency if we believe a patient has been the victim of abuse, neglect or domestic violence.
OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization.You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
Although your health record is the property of the Facility, the information belongs to you. You have the following rights regarding your health information:
You must submit your request in writing to Body Integrations Chiropractic. We may charge a fee for the costs of copying, mailing or other supplies associated with your request.
You must submit your request in writing to Body Integrations Chiropractic _ in addition, you must provide a reason for your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
You must submit your request in writing to Body Integrations Chiropractic. Your request must state a time period which may not be longer than six years from the date the request is submitted and may not include dates before June 1, 2016. Your request should indicate in what form you want the list'(for example, on paper or electronically). The first list you request within a twelve month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
You must submit your request in writing to Body Integrations Chiropractic. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.
You must submit your request in writing to Body Integrations Chiropractic. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.
You may obtain a copy of this Notice at our website, www.awesthoustonchiropractor.com To obtain a paper copy of this Notice, contact Body Integrations Chiropractic.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in the Facility and on the website. The Notice will specify the effective date on the first page, in the top right-hand corner. In addition, if material changes are made to this Notice, the Notice will contain an effective date for the revisions and copies can be obtained by contacting the Facility administrator.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the Facility or with the Secretary of the Department of Health and Human Services. To file a complaint with the Facility, contact Body Integrations Chiropractic. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Your information will be encrypted.