1. Us, DC Doctors and Dorris Chiropractic Inc.
2. Doctors of Chiropractic who provide services to you at DC Doctors and Dorris Chiropractic Inc and
3. All employees and subcontractors of DC Doctors and Dorris Chiropractic, Inc

We understand that medical information about you and your health is personal and we are committed to protecting this information. When you receive chiropractic treatment from us, a record of the treatment you received is made. Typically, this record contains your treatment plan, your history and physical, any X-ray and test results that you provide to us, your insurance information, and billing record. This record serves as a:

1. Basis for planning your treatment;
2. Means of communication for or between DC Doctors and Dorris Chiropractic Inc doctors and staff, DC Doctors and Dorris Chiropractic Inc and your other healthcare providers, if any, that you wish us to share them with; and a
3. Tool for assessing and continually working to improve the care rendered.

This Notice tells you the ways we may use and disclose you Protected Health Information (referred to herein as “medical information “) It also describes your rights and our obligations regarding the use and disclosure of medical information.

We are required by law to:

1. Maintain the privacy and security of your medical information.
2. Provide you with notice of our legal duties and privacy practices with respect to information we collect and maintain about you;
3. Abide by the terms of this notice; and
4. Notify you if we are unable to agree to a requested restriction.

The following categories describe different ways we may use and disclose your medical information. The examples provided services only as guidelines and do not include every possible use or disclosure.

1. For Treatment. We will use and disclose your medical information to provide, coordinate, or manage your chiropractic treatment at this clinic. For example, we may share your information with your primary care physician or other specialists upon request.
2. For Payment. We will use and disclose medical information about you so that payment for treatment you receive may be collected from you or another party.
3. For Health Care Operation. We will use and disclose medical information about you for our office operations. These uses, and disclosures are necessary to run the clinic in an efficient manner and provide that all patients receive quality care. For example, your medical records may be used in the evaluation of services, and the appropriateness and quality of chiropractic treatment we provide. Chiropractic services will be provided in either an open room where other patients are also receiving care or examination rooms. Other persons in the office may overhear some of your protected medial information during the course of care. Should you need to speak with the doctor at any time in private, a place for these conversations will be provided upon request. To the extent permitted by law, we may use cameras or other recording devices in our clinic. DC Doctors and Dorris Chiropractic Inc has cameras and recording devises that have a notice visibly posted informing you of such devices.
4. For Contacting You. We may use your address, phone number, e-mail and clinic records to contact you with notifications, text messages, birthdays and holidays related messaged, billing inquiries, information about treatment alternatives, or other health related information. If contacting you by phone, we may leave a message on your answering machine or voicemail.  
5. Appointment Reminders. We may use and disclose medical information to remind you or an appointment, if applicable.
6. As Required by Law. We will disclose medical information about you when required to do so by federal or state laws or regulations.
7. Health Oversite Activates. We may disclose medial information to a health oversite agency for activates authorized by law. Health oversite agencies include public and private agencies authorized by law to oversee the healthcare system. These oversight activities include, for example, adults, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, eligibility or compliance, and to enforce health – related civil rights and criminal laws.
8. Lawsuits and Disputes. If you are involved in certain lawsuits or administrative disputes, we may disclose medical information about you in response to a court or administrative order.
9. Law Enforcement. We may release medical information if asked to do so by a law enforcement official in response to a court order or subpoena.
10. Electronic Disclose. We may use and disclose your medical information electronically. For example, your medical information is maintained on an electronic health record. If another provider requests a copy of your medical records for treatment purposes, we may forward such records electronically.

1. Marketing. Marketing generally includes communication made to describe a health-related product or service that may encourage you to purchase or use the product or service. We will obtain your written authorization to use and disclose your medical information for marketing unless the communication is made face to face, involves a promotional gift of nominal value, or otherwise permitted by law. All other uses and disclosures of your information for marketing purpose requires your written authorization. You have the right to revoke such authorization in writing.

You have the following rights regarding medical information collected and maintained about you.

1. Right to Inspect and Copy. The right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to us. You can also ask to see or get an electronic copy of health information we have about you. Ask us how to do this.
2. Right to an Accounting of Disclosures. To request an “Accounting Disclosure.” This is a list of disclosures made of your medical information for purposes other than treatment, payment or healthcare operations. To request this list you must submit your request to us in writing. Your request must state a time period, which may not be longer than six (6) years. Your request should indicate in what form you want the list (for example, on paper or electronically).
3. Right to Request Restrictions. To request a restriction or limitation on the medial information we use OR disclose about you for treatment or payment. You also have the right to request a limit on medical information we disclose about you to someone who is involved in your care or the payment for your care. DC Doctors and Dorris Chiropractic Inc is required to agree to your request, but should any of us agree to your request, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions you must make your request in writing and include (1) what information you want to limit; (2) whether you want to limit our use and /or disclose; and (3) whom you want the limits to apply.
4. Rights to revoke and Authorization. There are certain types of uses or disclosures that require your express authorization. For example, we may not sell your personal information to a third party for marketing purposes, without first obtaining your authorization. If you provide certain authorization for a particular use or disclosure of your medical information, you may revoke such authorization in writing by contacting us. We will honor your revocation except to the extent that we have already taken action in reliance of the specific authorization.
5. Rights to Receive a copy of this document. You have the right to obtain a paper copy of this document upon request.

We reserve the right to change our practices and to make the new provisions effective for all the medical information we maintain. Should our information practices change, we will post the amendment Notice of Privacy Practices in our office. You may request a copy be provided to you by contacting us.

Payment is expected prior to the completion of your treatment. For your convenience, our office accepts many forms of payment. Below is a list you can choose from:

- Cash or Check
- Credit/Debit Cards: Visa, Mastercard, or Discover Card
- Health Savings Account Card (HSA)

- DC Doctors requires payment prior to the completion of your treatment.

- You are held one hundred percent financially responsible for the services rendered in this office. If you accumulate a balance, you will be notified, and payment is due upon receipt. After one hundred and twenty days past due your case will be sent to collections with a collection fee that matches your balance, thus doubling your overall account balance and amount owed.

- We offer a variety of payment plans and options that allows you and your family to get the chiropractic care you need, no matter what your budget is. Please note our courtesy 10% OFF “At Time-of-Service Discount” will NOT apply if payment is not at the time of service. Below is an incomplete list of common pricing options.

Single Visit Chiropractic Spine and Extremity Care - $69.90 
     98941 + 98943-51 Includes 10% OFF at time-of-service discount                                                                                                                                             

The primary treatment used by Doctors of Chiropractic is spinal manipulation therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument (examples: activator, toggle speeder board, drop piece) upon your body in such a way as to move your joints. That may cause an audible "pop" or "click" much as you have experienced when you "crack" your knuckles. You may feel a sense of movement. The Chiropractic adjustment serves to normalize function (movement) of the spine and/or extremities as well as surrounding structures, thus, having a positive impact on the health and function of the body.

Your doctor will conduct a clinical analysis with the primary purpose of detecting the presence of joint dysfunction (segmental and somatic dysfunctions) and its effects on your health. The purpose of chiropractic care is to promote health through the correction of joint restrictions also called subluxations. If you have other conditions besides the presence of joint dysfunction (segmental and somatic dysfunctions), your doctor will refer you to your primary healthcare physician or the appropriate health care provider. Since there are so many variables affecting one’s health, it is difficult to predict the time schedule, degree of response, or the efficacy of chiropractic care for any given patient. However, the doctor will make recommendations for clinical management based upon known circumstances and clinical experience.

- Manipulative Therapy
- Vital Signs
- Palpation
- Range of Motion Testing
- Orthopedic Testing
- Functional Testing
- Basic Neurological Testing
- sEMG Testing
- Ultrasound
- Muscle Strength Testing
- Urine/Blood Testing
- Postural Testing
- Percussion Instruments
- EMS/TENS
- Physiotherapy
- Hot &/or Cold Therapy
- Mechanical Traction
- Manual Traction
- Vibration Instruments/RRT
- Cupping
- Lifestyle/Nutritional Advice  

As with any healthcare procedure there are certain complication which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. The Doctor will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to the Doctor's attention it is your responsibility to inform the Doctor.

Where joint and/or soft tissue dysfunctions (segmental and somatic dysfunctions) are found to be present, chiropractic care is usually beneficial and seldom leads to adverse reactions. Fractures are rare occurrences and generally result from some underlying weakness of the bone which we check for during the taking of your history and during examination and X-ray. Stroke and /or arterial dissection caused by chiropractic manipulation of the neck has been the subject of ongoing medical research and debate. The most current research on the topic is inconclusive as to a specific incident of this complication occurring. If there is a causal relationship at all it is extremely rare and remote. Unfortunately, there is no recognized screening procedure to identify patients with neck pain who are at risk of arterial stroke. To further reduce risks, it is the patient’s responsibility to make it known whether they are suffering from: pathological conditions (latent or otherwise), illnesses, injuries, or deformities which otherwise might not come to the attention of your doctor. By signing this form, you affirm that you have been open and truthful in disclosing your health history and give the doctor permission and authority to examine and care for you.

Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer its postponed.

Although Doctors of Chiropractic specialize in the analysis of proper spinal and extremity biomechanics, we are not internal medical, neurologists, or surgical specialists. Therefore, you should be mindful of your own symptoms and should secure other opinions should you have any concerns as to the nature of any other symptoms or concerns you may have regarding your
health. Your Doctor of Chiropractic may express an opinion as to whether or not further consultation is necessary, but you the patient are responsible for the final decision and any subsequent action taken.

Other treatment options for your condition may include:
• Self-administered, over-the-counter analgesics and rest
• Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers
• Hospitalization
• Surgery

If you chose to use one of the above noted ‘other treatment’ options, you should be aware there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.

Please refer to the provided copy and posted Patient Gowning Policy and Procedures handout. These policies and procedures apply to all situations at DC Doctors and Dorris Chiropractic Inc including: examinations, treatments, therapies, use of sEMG, postural analysis, and/or modalities. Further these policies and procedures are applicable to all of the Doctors of Chiropractic, chiropractic technicians, staff, and interns at DC Doctors and Dorris Chiropractic Inc. Questions should be directed to the President of DC Doctors and Dorris Chiropractic Inc: Dr. Andrea Dorris, DC.

It is unlawful to wiretap, eavesdrop, or record confidential conversations and/or use a camera or other recording device to review or record individuals without their permission in California without the knowledge and consent of all parties. At DC Doctors and Dorris Chiropractic Inc all personal cameras, audio and video recording devices are prohibited to be used by patients and/or visitors in the office. DC Doctors and Dorris Chiropractic INC has posted security surveillance signs, “SMILE YOU ARE ON CAMERA”, in the reception area where video security surveillance is taking place. Our office uses video security surveillance as a deterrent against violence and theft. By signing below, I agree to comply with this policy and will not use audio and/or video recording devices at DC Doctors and Dorris Chiropractic Inc.

I hereby request and authorize Dr. Andrea Dorris, DC; Jeremy Dorris, DC, and the Doctors at DC Doctors and Dorris Chiropractic Inc to perform an examination including diagnostic tests and render chiropractic adjustments and other treatment to my minor son/daughter. This authorization also extends to all other doctors and office staff members and is intended to include radiographic examination at the doctor’s discretion.

As of this date, I have the legal right to select and authorize health care series for the minor child named above. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify this office.