Houston Medical Group

Houston Medical Group is committed to protecting the privacy and confidentiality of all your medical and personal information. By signing this form, you acknowledge and agree to the following:

Protection of Information: All medical, financial, and personal information you provide will be treated as strictly confidential. This information will be used solely to provide medical care, process insurance claims, and comply with applicable legal requirements.

Disclosure of Information: Your protected health information (PHI) will only be disclosed: (1) to healthcare providers directly involved in your treatment; (2) to your insurer or other payers for billing and reimbursement purposes; (3) as required or permitted by law; (4) with your prior written authorization for any other purpose.

Your Rights: You have the right to: inspect and obtain a copy of your medical record; request corrections to your medical information; receive an accounting of disclosures we have made of your information; request restrictions on how we use or disclose your information; receive confidential communications; and file a complaint if you believe your privacy rights have been violated.

Notice of Privacy Practices: You have the right to receive our full Notice of Privacy Practices, which describes in detail how we may use and disclose your protected health information. By signing below, you confirm that you have received or have been offered a copy of that notice.

Electronic Security: We take reasonable and appropriate measures to protect electronic protected health information (ePHI) against unauthorized access, use, disclosure, alteration, or destruction.

By signing below, I acknowledge that I have read and understood this Confidentiality Statement and that I consent to the use and disclosure of my information as described herein and in Houston Medical Group's Notice of Privacy Practices.

Authorization for Disclosure of Protected Health Information

I, the undersigned, hereby authorize Houston Medical Group to use and/or disclose my protected health information (PHI) in the manner described in this document, in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and its applicable regulations.

Information that may be disclosed: All medical information related to my treatment, diagnosis, medical history, laboratory test results, radiological images, medication records, and any other information related to my medical care at Houston Medical Group.

Persons or entities authorized to receive information: Information may be disclosed to: (1) insurance companies, health plans, and other payers responsible for payment of medical services rendered; (2) other physicians, hospitals, or healthcare providers involved in my treatment; (3) attorneys or legal representatives handling claims related to my treatment; (4) government agencies as required by law; (5) any other person or entity that I expressly authorize in writing.

Purpose of disclosure: Coordination of medical care, insurance billing and reimbursement, healthcare operations activities, compliance with legal requirements, and any other purpose related to my treatment and well-being.

Validity period: This authorization will remain in effect until I revoke it in writing or until the treatment and billing process related to my care at Houston Medical Group is complete.

Right to revoke: I have the right to revoke this authorization at any time by written notice to Houston Medical Group. I understand that revocation will not affect any disclosure already made in reliance on this authorization.

Right to refuse: I understand that I may refuse to sign this authorization, but that if I do so, Houston Medical Group may not be able to provide me with the requested treatment or services, or to process insurance claims on my behalf.

Protections: I understand that once my health information is disclosed pursuant to this authorization, it may no longer be protected by federal privacy regulations (HIPAA) if the recipient is not subject to those regulations.

By signing below, I confirm that I have read and understood this authorization, and that I voluntarily consent to the disclosure of my protected health information as described in this document.

Nature of Treatment: I have been informed that chiropractic medicine and physical therapy involve the use of manual techniques, therapeutic exercises, physical modalities, and other related procedures for the treatment of neuromusculoskeletal conditions and other health conditions. Procedures may include, but are not limited to: spinal manipulation and adjustment, joint mobilization, soft tissue therapy, traction, ultrasound, electrical stimulation, heat, cold, and therapeutic exercise.

Risks of Treatment: I understand that, as with any medical procedure, chiropractic treatment and physical therapy carry certain risks. These risks may include, without limitation: temporary pain or discomfort in the treated area; temporary aggravation of existing symptoms; fractures, especially in patients with osteoporosis; intervertebral disc injuries; dislocations; sprains and muscle strains; and, in extremely rare cases, vertebral artery injury that may result in stroke or other neurological complications.

Treatment Alternatives: I have been informed that alternative treatments are available, including but not limited to: medications, surgery, rest, other forms of physical therapy, and refraining from treatment. I have had the opportunity to discuss these alternatives with my healthcare provider.

Voluntary Consent: I understand that my participation in treatment is completely voluntary and that I have the right to withdraw my consent and discontinue treatment at any time without negatively affecting my future medical care.

Liability Release: With full knowledge of the risks involved, I, the undersigned (patient or legal guardian), hereby release, discharge, and hold harmless Houston Medical Group, its physicians, chiropractors, physical therapists, employees, agents, and representatives from any and all civil liability for any injury, damage, loss, or expense that may arise directly or indirectly as a result of the chiropractic or physical therapy treatments to which I consent herein, except in cases of gross negligence or intentional misconduct.

Questions: I have had the opportunity to ask questions about the nature, purpose, risks, and alternatives of the proposed treatment, and all my questions have been answered to my satisfaction.

By signing below, I confirm that I have read, understood, and voluntarily agree to this Informed Consent and Liability Release for Chiropractic Medicine and Physical Therapy.

Assignment of Insurance Benefits: I hereby irrevocably assign and transfer to Houston Medical Group all medical benefits and/or insurance payments to which I am entitled for services rendered. I authorize and direct my insurance company, health plan, motor vehicle insurance company, third-party liability insurance company, and/or any other payer to pay directly to Houston Medical Group all applicable benefits for medical services rendered.

Personal Financial Responsibility: I understand and agree that I am personally responsible for any balance not covered by my insurance, including but not limited to: deductibles, co-insurance, co-payments, non-covered services, or any amount that my insurer refuses to pay for any reason. I agree to pay such balances according to Houston Medical Group's payment terms.

Authorization to Obtain Information: I authorize Houston Medical Group to obtain information regarding my insurance coverage, eligibility, and benefits, and to submit claims on my behalf to any insurance company, health plan, or other payer for services rendered.

Personal Injury Cases: In cases involving personal injury or automobile accident claims, I understand and agree that Houston Medical Group may hold a medical lien on any settlement, judgment, or award I receive. I authorize my attorney, if I have one, to withhold sufficient funds from the proceeds of any settlement to satisfy the balance owed to Houston Medical Group, and to pay such amount directly to Houston Medical Group.

Authorization to Share Information: I authorize Houston Medical Group to disclose necessary medical information to my insurance company, legal representative, or other payers for the purpose of processing claims and obtaining payment for services rendered.

Duration: This assignment of benefits shall remain in effect until revoked in writing. A photocopy of this authorization is as valid as the original.

By signing below, I confirm that I have read and understood this Assignment of Benefits document and that I agree to its terms voluntarily.