PATIENT CONSENT FORM
The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy, The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients’ consent for uses and disclosures of health information about the patient to carry Out treatment, payment, or health care operations.
As our patient we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care the is in your best interest.
We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories this only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.
You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.
If you have any objections to this form, please ask to speak without HIPAA Compliance Officer.
You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.
Print Name:___________________________ Signature:_________________________ Date:
COMPLIANCE ASSURANCE NOTIFICATION FOR OUR PATIENTS
To Our Valued Patients:
We are committed to protecting your privacy and the confidentiality of your protected health information (PHI). The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule establishes federal standards to safeguard your health information.
Our employees, managers, and providers receive ongoing training on HIPAA requirements, including the Privacy Rule, to ensure we handle your information appropriately and ethically. We maintain high standards of integrity in all services we provide.
It is our policy to use and disclose PHI only as permitted or required by law. We have implemented policies and procedures, including a compliance program, to prevent improper uses or disclosures and to meet our obligations under HIPAA and other applicable regulations.
Regarding Substance Use Disorder (SUD) Records (if applicable): If your records include information about substance use disorder diagnosis, treatment, or referral from a federally assisted program (protected under 42 CFR Part 2), we follow stricter confidentiality rules. Many uses and disclosures of these records require your written authorization, even for treatment, payment, or health care operations. We will not use or disclose these records in civil, criminal, administrative, or legislative proceedings without your consent or a court order (with notice to you and an opportunity to respond), except as otherwise permitted by law. For more details, please review our full Notice of Privacy Practices.
We recognize that no system is perfect. We encourage employees and patients to report any concerns about potential privacy or security issues without fear of retaliation. We welcome your feedback on any aspect of our services so we can address issues promptly and improve.
Thank you for entrusting us with your care. We value you as our patient.
Clyde Park Chiropractic/ West Michigan Wellness Center;[Contact Information for Privacy Officer Dr. Gladish, February 16, 2026
Thank you for being one of our highly valued patients.