CHIROPRACTIC FAMILY AND SPORTS INJURY CENTER
801 Franklin Avenue
Franklin Lakes, N.J. 07417
(201) 891-5599

Privacy Practices
Notification
Agreement and Consent Form


By signing below, I acknowledge that I have been advised by Chiropractic Family and Sports injury Center, that a copy of the Notice of Privacy Practices will be provided upon my request. The notification advises how health information about me may be used and disclosed by the office and the facilities listed in the notice, and how I may obtain access to and control this information.

Finally, by signing below , I consent to the use of my health information to treat me and arrange for my medical care, to seek and receive payment for services given to me, and for the business operation of the office, it’s staff, and the facilities listed in the notice.


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Signature of Patient or Personal Representative


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Print Name of Patient or Personal Representative

DATE_____________


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Description of Personal Representative’s Authority