1. Patient Consent & Acknowledgment (Updated 2026)
This is the one-page form you have patients sign and initial. It references your full "Notice of Privacy Practices" (NPP), which should be posted in your lobby.
COLORADO CHIROPRACTIC CLINIC, P.C.
Patient Privacy Consent & Acknowledgment of Rights
I give consent for Colorado Chiropractic Clinic, P.C. ("Practice") to use and/or disclose my Protected Health Information (PHI) for the purposes of Treatment, Payment, and Health Care Operations (TPO).
I. Acknowledgment of New 2026 Privacy Standards:
- Notice of Privacy Practices (NPP): I acknowledge that I have been provided with (or had the opportunity to review) the Practice’s Notice of Privacy Practices, updated as of February 2026. I understand this policy may change and I can request a current copy at any time.
- Notice of Redisclosure: I understand that once my health information is disclosed to an authorized recipient, it may be subject to redisclosure by that recipient and may no longer be protected by federal HIPAA privacy laws.
- Substance Use Disorder (SUD) Protections: I understand that any records received by this Practice regarding substance use disorder treatment (protected under 42 CFR Part 2) are subject to stricter protections. These records will not be used in legal proceedings against me without my specific written consent or a court order.
II. My Patient Rights:
- Right to Restrict: I have the right to request restrictions (in writing) on how my PHI is used. While the Practice is not generally required to agree, it must agree to restrict disclosure to a health plan if I have paid for the service in full out-of-pocket.
- Right to Revoke: I may revoke this consent in writing at any time, except to the extent that the Practice has already acted in reliance upon it.
- Right of Access: I have the right to inspect, take notes on, or take a digital photograph of my medical records in person.
- Fundraising: If the Practice uses PHI for fundraising, I have a right to opt-out of such communications at any time.