HIPAA Patient Consent Form

We are required by the health insurance portability and accountability act of 1996 (HIPAA) to maintain the privacy ofyour protected health information (PHI) and to provide you with a notice of privacy practices. Our notice of privacypractices provides information about how we may use and disclose your PHI, and contains a section describing yourrights as a patient under the law. You have the right to review our notice before signing this consent and you areadvised to do so.

By signing this form, you consent to our use and disclosure to third parties of your PHI for treatment, payment,healthcare operations and for certain marketing purposes, as described in our Notice of Privacy Practices. If you signthis Consent but later change your mind, you have the right to revoke this Consent by delivering to us a written, dateddocument signed by you. However, such a revocation shall not affect any disclosures we have already made inreliance on your prior consent.

The patient understands that:

The clinic has a Notice of Privacy Practices. The patient has received, and had the opportunity to review, this Notice before signing the consent. The Clinic encourages all patients to review the Notice of Privacy Practices.

The Clinic reserves the right to modify the Notice of Privacy Practices to keep up with changes in the law or office practices. We will make all modifications available for review by patients.

Protected health information may be disclosed or used for treatment, payment, or healthcare operations, and for certain marketing purposes.

The Clinic or its business affiliates may use your PHI to contact you with educational and promotional items in the future via email, U.S. Mail, telephone, fax and/or prerecorded messages. We WILL NOT ever sell or “SPAM” your personal contact information.

The patient has the right to restrict the uses of his or her information, but the Clinic does not have to agree to all such restrictions.

The patient may revoke this Consent in writing at any time and all future disclosures that require the patient's prior written consent will then cease.

The Clinic may condition receipt of treatment upon the execution of this consent.

The Consent was signed by:Printed Name - Patient or Representative

Signature Date

Relationship to Patient(if other than patient)

Witness:Printed Name - Clinic Representative

Signature Date

Consent for Chiropractic Treatment

Chiropractic examination and therapeutic procedures (including spinal adjustments, ultrasound, heat application,electrotherapy and manual muscle therapy) are considered safe and effective methods of care. Occasionally, however,complications may arise. Any procedure intended to help may have complications. While the chances of experiencingcomplications are small, it is the practice of this clinic to inform our patients about them. Side effects include but are notlimited to, soreness, inflammation, soft tissue injury, dizziness, burns, and temporary worsening of symptoms. More seriouscomplications are extremely rare and their association with spinal adjustments (manipulation) is debated. Thesecomplications include injury to the arteries in the neck which may be associated with stroke and serious neurologicimpairment, injuries to the spinal discs, and spinal fractures. Serious complications are estimated to be in range of .5- 2incidents per million adjustments for adjustments of the neck, and 1 per million for adjustments of the lower back. Additionalinformation on side-effects, complications and effectiveness of spinal adjustments is available upon request.

I have read and understand that the above statements regarding treatment side-effects. I also understand that there is noguarantee or warranty for a specific cure or result.

Patient Signature: Date:

Consent for Massage Therapy

I (Please print Name) understand the following:

• A massage therapist does not diagnose illness or disease, or any other disorder.• Massage therapy is not a substitute for Medical Examination or medical care, and is recommended that I am

currently working with my primary caregiver for any condition I may have.• The relationship between the client and the therapist is a confidential one and that all information provided to the

therapist will be kept confidential.• My body will be draped at all times for comfort, security and warmth.• I have right to request and require that any procedure or technique be modified, changed or stopped.• I have the right to have any part of my body not massaged (please let the therapist know).• The massage therapist is a licensed professional and has the right to terminate session under the circumstances where

I use unwanted, harmful or offensive language or behavior.• I have stated all my known physical conditions, medical conditions, and medications. I will keep my massage

therapist updated on any changes.• I will inform the therapist of any discomfort, so the application of pressure or strokes may be adjusted accordingly to

fit my level of comfort.• By signing this form, I also give consent for future sessions. I have read this form and hereby freely give my

permission to be massaged.

As a minor, I have been informed in the presence of my guardian.

Patient Signature: Date:

Therapist Signature: Date:

Consent for Acupuncture Therapy

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scopeof the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by theacupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me whileemployed by, working or associated with or serving as back-up for the acupuncturist named below, including thoseworking at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.

I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping,electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I have beeninformed that acupuncture is a generally safe method of treatment, but that it may have some side effects, includingbruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burnsand/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps.Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nervedamage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, althoughthe clinic uses sterile disposable needles and maintains a clean and safe environment.

I understand that while this document describes the major risks of treatment, other side effects and risks may occur.I understand that all my records will be kept confidential and will not be released without my written consent.

By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, havebeen told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to askquestions. I intend this consent form to cover the entire course of treatment for my present condition and for anyfuture condition(s) for which I seek treatment.

Acupuncturist Name:

Patient Signature: Date:(Or Patient Representative- Indicate relationship if signing for patient)

PATIENT FINANCIAL RESPONSIBILITY FORM

Thank you for choosing D'Vida Injury Clinic & Wellness Center as your healthcare provider. We are honored by your choice and are committed to providing you with the highest quality healthcare. We ask that you read and sign this

form to acknowledge your understanding of our patient financial policies.

Patient Financial Responsibilities

• The patient (or patient’s guardian,) is ultimately responsible for the payment of his/her treatment and care.• We are pleased to assist you by billing for our contracted insurers however, the patient is required to provide us with the most correct andupdated information about their insurance and the patient will be responsible for any charges incurred if the information provided is notcorrect or updated.• Patients are responsible for the payment of co-pays, co-insurance, deductibles and all other procedures ortreatments not covered by their insurance plan. Payment is due at the time of service and for yourconvenience we accept cash, check, and most major credit cards at our office.Patients may incur, and are responsible for the payment of additional charges. These charges may include (but are not limited to):

• Charge of $25 for returned checks• There also may be fees applicable for medical record copies in the amount of $0.25 per page copied or $5.00 for every 100 pages on a

CD.• Charge of $35 for missed appointments without 24-hours advance notice. If you cancel your appointment without providing a 24-

hour advance notice, or no-show for an appointment or a last minute reschedule, there will be a $35.00 charge collected at your next appointment. Should the appointment reminder system fail or neglect to call you, the responsibility to know when your appointment is scheduled belongs to the patient and will not negate the $35.00 charge for missing an appointment.

By my signature below, I acknowledge and understand that it is ultimately my responsibility and obligation to be aware of my insurance’s requirements, coverages, deductibles and payments. Co-pays, Coinsurance,Time of Service Discount:I understand that I am responsible to pay in full prior to leaving. If I ask to be billed, I understand the that The Time of Service Discount will not apply & I will be charged the full Oregon Fee Schedule..

I acknowledge that I assume full financial responsibility for services rendered to me, if my insurance carrier denies or does not cover my claim for these services. I understand the terms of this form and accept financial responsibility with or without the use of insurance coverage.

Patient Authorization

• By my signature below, I hereby authorize D'Vida Injury Clinic & Wellness Center and the physicians, staff & any 3rd partybilling department to release medical and other information acquired in the course of my examination and/or treatment to thenecessary insurance companies, third-party payers, and/or other physicians or healthcare entities required to participate in mycare. I hereby authorize assignment of financial benefits directly to D'Vida Injury Clinic & Wellness Center and any associatedhealthcare entities for services rendered as allowable under standard third-party contracts. I understand that I am financiallyresponsible for charges not covered by this assignment. I understand thataccount balances not paid by my insurance company within 90 days are the patient’s/my responsibility. I authorize D'Vida Injury Clinic &Wellness Center personnel to communicate by mail, answering machine message, voice mail, and/or email according to the information Ihave provided in my patient registrationinformation.

I have read, understand, and agree to the provisions of this Patient Financial Responsibility Form:

_____________________________________________________________________________________________ Signature of Patient or Legal Guardian Date

Waiver of Authorization: I do not wish to have information released and prefer to pay at the time of service and/or to be fully responsible for payment of charges and /or to submit claims to insurance at my discretion.

_____________________________________________________________________________________________ Date Signature of Patient or Legal Guardian

3835 SW 185th Ave STE. 400, Beaverton,

OR 97078

T:503-626-2166 F: 503-641-6665