Notice of Privacy Practices Acknowledgement

Rawlins Chiropractic

801 West Maple

Rawlins WY 82301

  I understand that, Under the health insurance portability & accountability act of 1996 ("Hippa"), I have the certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

*Conduct, Plan and direct my treatment and follow up among the multiple health care providers who may be involved in that treatment directly and indirectly.

*Obtain payment from third party payers.

*Conduct normal health care operation such as quality assessments and physician certifications.

  I have received, read and understand your notice of privacy practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its notice of privacy practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the notice private practices.

  I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions but if you do agree than you are bound to abide by such restrictions.

Missed Massage Appoinment Policy

Rawlins Chiropractic

801 West Maple

Rawlins WY 82301

Our goal is to provide individualized care in a timely manner. No-shows, late shows and cancellations inconvenience those individuals who need access to care as well as the Massage Therapist. We would like to remind you of our policy regarding missed massage appointments.

  In order to be respectful of the needs of other patients, please be courteous and call Rawlins Chiropractic

promptly if you are unable to show up for an appointment. This time will be reallocated to someone who is in need of treatment. If it is necessary to cancel your appointment, we ask that you call at least 24 hours in advance. Appointments are in high demand, and your early cancellation will allow another patient access to timely care.

  To cancel your appointment, please call 307-324-7000. If you do not reach the receptionist, please leave a detailed message on our voicemail including your name and phone number. We will return your call promptly.

  NO SHOW POLICY: A  "no show", is a patient who misses an appointment with out canceling it. A failure to be present at the time of a scheduled appointment will be recorded in the patients chart as a "no show".

  Patients that are a "no show" more than once will not be allowed to re-schedule a massage with out speaking to the office manager first. Patients will be notified that any future massage appointments he/she has in the future will  be canceled. A reasonable effort must be made to contact the patient to let them know their appointment(s) has been canceled and it must be documented.