Here at Nebraska Family Chiropractic and Acupuncture, we respect your privacy, we do not sell or release your information to third parties. There will be cases along the course of your care where information will need to be released in certain circumstances. You authorize Nebraska Family Chiropractic and Acupuncture to release to employer groups, government agencies (Medicare, Medicaid, Champus, State or Federal governments, etc.), insurance companies, or other third-party payers and their agents, and its collection representative and attorneys, the following “Patient Information”: medical history, diagnoses, and procedures performed, course of treatment, plan of care, prognosis, supplies and/or such other information that may be requested for the purpose of determining eligibility and availability of Patient’s benefits, obtaining authorization/payment for the Patient’s health care services or billing and collection of amounts due to Universal Wellness Source for services rendered. In the case of Patient Information released for purposes of payment of Patient Charges, this authorization shall be valid only for the period of time necessary to process payment claims. You agree to pay any Patient Charges that are denied or are ineligible for medical reimbursement benefits as a result of your refusal or revocation of consent to disclose Patient Information.

 

You further authorize any individual health care professionals, including treating physician(s), to provide Nebraska Family Chiropractic and Acupuncture, or its designee, with Patient Information for quality assurance and/or risk management purposes. Finally, in the event that the Patient’s employer, or an insurance company representing such employer, requests Patient Information relating to healthcare services provided for worker’s compensation injuries, it is understood and agreed that Universal Wellness Source is required, under state law, to release copies of such information to such employer or insurance company without the authorization of Patient or Patient’s representative. Again, here at Nebraska Family Chiropractic and Acupuncture we strive to provide you with the best care possible and in order to do that this consent is needed.

The Practice’s Privacy Notice has been provided to you prior to you signing the consent for treatment. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law. A copy of the Privacy Notice is available for you upon your request.