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FORM Acupuncture HIPAA Consent new - DrAllexi.com

FORM Acupuncture HIPAA Consent new - DrAllexi.com 2025

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4.3 out of 5

40 votes

The document is a patient information form for Allexi Chiropractic and Acupuncture, detailing the clinic's privacy practices under HIPAA, patient rights regarding health information, and consent for treatment by Dr. Jasmine S. Allexi. It outlines the services provided, including chiropractic care and acupuncture, along with associated risks and billing policies.

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Click ‘Get Form’ to open it in the editor.
Begin by filling in your personal information, including your first name, last name, preferred name, address, city, state, zip code, and birthdate. Ensure all details are accurate for effective communication.
Indicate your gender and provide your home and cell phone numbers. If applicable, include information about your children’s ages and names.
Select your marital status from the options provided. This helps the clinic understand your personal circumstances better.
Review the NOTICE OF PRIVACY PRACTICES section carefully. It outlines how your health information will be used and your rights regarding that information.
Sign and date the form at the bottom to confirm that you understand and consent to the terms outlined in the document.

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Versions	Form popularity	Fillable & printable
2016	4.5 Satisfied (59 Votes)
2012	4.3 Satisfied (40 Votes)

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