Anchor Chiropractic                                                Notice of Privacy Practices     This is our Consent for Purposes of Treatment, Payment and Healthcare Operations form                                          that all patients will be asked to sign. My "protected health iniformation" means health information,including my demographic information, collected from me and created or received by my physician. This protected health information relates to my past, present or future physical or mental health or condition and identifies me,or there is a reasonable basis to believe the information may identify me.      I consent to the use or disclosure of my protected health information by Anchor Chiropractic for the purpose of diagnosing or providing treatment to me,obtaining payment for my health care bills or to conduct health care operations of Anchor Chiropractic.  I understand that Dr. M.Foxworthy may refuse to diagnose or treat me, if I do not consent to the use or disclosure of my protected health information for the above stated purposes. (My signature on this document is evidence of this consent.)      I understand I have the right to request a restriction as to how my protected health information is used or disclosesd to carry out treatment, payment or healthcare operations of the practice. Anchor Chiropractic is not required to agree tothe restrictions that I may request, the restriction is binding on Anchor Chiropractic and Dr.M.Foxworthy.      I understand I have a right to review Anchor Chiropractic's Notice of Privacy Practices prior to signing this document.Anchor Chiropractic's Notice of Privacy Practices has been provided to me. The Noticeof Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operatoions of Anchor Chiropractic. The Notice of Privacy Practices for Anchor Chiropractic is also posted in the waiting room of the office.  This Notice of Privacy Practices also describes by  rights and Anchor Chiropractic's duties with respect to my protected health information.