CAROLYN DAYIS-WILLIAMS, D.C. -- ADVANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St. Houston, TX 77004 (713) 529-6760 Clinic (713) 526-0655 Fax

PATIENT DEMOGRAPHIC INFORMATION

Name

How Did You Hear About Us or Referred By:

Social Security # Last

Address

First Middle

Street

Phone (H) _ ( C ) _

City

Email:

State Zip

Date of Birth

Sex Male Female

Employer

Marital Status Married Single Divorced Widowed Driver's License #_ Work Number

Employer Address_ Street

P R I M A R Y C A R E P H Y S I C I A N :

Address:

City State Zip

Phone:

Special ity: Date Last Seen:

R E S P O N S I B L E P A R T Y : P L E A S E F I L L O U T I F NOT S AME AS P A T I E N T

Name

Address

(INSURED POLICY HOLDER, OR PARENT/GUARDIAN)

Social Security #

Street

Date ofBirth_

Employer

City State Zip

Sex Male Female Relationship to Patient Self Spouse Child Other

Work Phone

Employer Address_ Street

I N S U R A N C E I N F O R M A T I O N ;

Medicare Ins Co & Number

City State Zip

Medicaid Ins Co. & Number

Primary Insurance Name

Insurance Policy/ID Numher_

Insurance Address

Insurance Phone #_

Group #

Street E M E R G E N C Y C O N T A C T I N F O R M A T I O N :

Name

City State Zip

Relationsliip_ .Phone (H)_ _ ( C ) .

I HEREBY AUTHORIZE CAROLYN DAVIS-WILLIAMS, D.C. TO APPLY TO MY INSURANCE CARRIER, FOR BENEFITS ON MY BEHALF FOR COVERED SERVICES RENDERED BY CAROLYN DAVIS-WILLIAMS, D.C. I REQUEST THAT PAYMENT FROM MEDICARE BE MADE DIRECTLY TO CAROLYN DAVIS-WILLIAMS. D.C. I AGREE TO PAY FOR ANY SERVICES NOT COVERED BY MEDICARE. THE OFFICE WILL ASSIST ME AS MUCH AS POSSIBLE TO GET THE CARRIER TO PAY MY CLAIMS, HOWEVER. THE CONTRACT IS BETWEEN ME AND THE INSURANCE CARRIER. SO I REALIZE THAT PAYMENT FOR MY HEALTHCARE IS MY SOLE RESPONSIBILITY. I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL. THIS AUTHORIZATION APPLIES TO ALL OCCASIONS OF SERVICE UNTIL REVOKED B Y ME IN WRITING.

PATIENT'S SIGNATURE DATE I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS ANY INSURANCE CLAIM SUBMITTED BY THE CLINIC. I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL. I ALSO GIVE CAROLYN DAVIS-WILLIAMS, D.C. PERMISSION TO RELEASE DEMOGRAPHIC INFORMATION TO HOSPITAL, LABORATORIES, AND RADIOLOGY AS NEEDED TO SCHEDULE TESTS OR OTHER MEDICAL PROCEDURES FOR ME.

PATIENT'S SIGNATURE DATE

Doctor's Signature Date

CAROLYN DAYIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax

Page 1 PATIENT H E A L T H , SOCIAL & F A M I L Y HISTORY Date _

Information contained herein will not be released except as you have authorized and will be used by your doctor in decisions regarding your care, so please answer all questions honestly and to the best of your knowledge.

Last Name: First Name: Middle: Age: Ht: Wt: Marital Status: Sf5 M^? D 4 Separated ^ Sex: ^ M t«F D o y o u h a v e o r h a v e y o u h a d : Please arch all that apply ( I f yes, give date of occurrence) Stroke Rheumatic Heart Congenital Heart Colitis Sleep Apnea Hay Fever Migraine Asthma Diarrhea Excessive Drowsiness Bleeding Tendency Tuberculosis Blood Clots Pneumonia Loud Snoring Bronchitis Thyroid Problems High Blood Pressure Cancer Shortness of Breath Seizures Bladder Infection ' ' ' Anxiety or Depression Heart Attack Chest Pain Diabetes Arthritis High Cholesterol Stomach Ulcers Heart Failure Kidney Disease Tonsillitis AIDS/+HIV Glaucoma Gall Stones •t Leukemia Broken Bones Depression Anxiety Suicide Attempt

Is this visit as a result o f an injury or accidents: Auto Date W o r k Related Date Other T y p e o f In jury : Deseribe Details Date

Primary Reason for T h i s V i s i t ? 1") Date o f Onset

2"'') 3^'') 4th)

Have you had treatment for this condition? Y N I f so What?

Doctor's Name: Speciality: When Seen? ^ _ D r . Phone Number:

P A I N L E V E L T O D A Y (0 N O P A I N / 10 W O R S T P A I N E R ) 1 2 3 4 5 6 7 8 9 10 ( W O R W / 0 M E D S )

Type o f Pain/Condition? D u l l * A c h i n g * Sharp * B u m i n g * Throbbing * Nagging * Numbness * T i n g l i n g * Radiate * M o v e A r o u n d

Name and Dates o f ai l operations you have had: .

Name any drugs to w h i c h y o u are allergic:

Serious illnesses you have had; .

Serious Injuries or accidents: .

A R E Y O U P R E S E N T L Y T A K I N G ANY O F T H E F O L L O W I N G MEDICATIONS? Aspirin, Advil , Anacin Laxatives Seizure medicine Blood pressure pills Sleeping pills Shots Cortisone Thyroid medicine Water pills Chough medicine Headache pills Antibiotics Digitalis Medicine for arthritis Cold medication Hormones Tranquilizers Birth control pills Insulin or diabetic pills Weight reducing pills Pain medicine Iron Poor blood medication Blood thinning pills Over the counter med Vitamins Medicine for depression Eye drops Ulcer medicine Cholesterol medicine Other drugs not listed Other medicine

Please check all that apply : YES ^ NO ^ If yon smoke or have you ever smoked, How much? How many years? If quit, when? Y E S ^ N O ^ Date of last chest X-Ray [ YES ^ NO «j Do you usually drink over 6 cups of caffeinated beverages per day?

Doctor's Signature Date

CAROLYN DAYIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax

Please check all YESt? NOf? Y E S ^ N0(? YEStS m4 Y E S ^ N O d YESf? N O ^ YESt ! NOt? Y E S d N O ^ Y E S ^ N O d YES ^ NO t! YESf } N O ^ Y E S ^ N0«? YES «f NO t? YES«5 N O ^

t h a t a p p l y : Continued Confidential Personal History Page T w o

Do you regularly drink alcohol, wine, or beer? How much? Do you exercise regularly? What and How Often? Do you sleep wel l? Mattress Age Do you have pets? Birds C a t s _ Dogs Other Do you use recreational drugs? What Do you eat regularly? Times a Day? 1 _ 2 _ 3 _ Healthy?_ Do you have regular recreation t ime? Type?

. Healthy Sometimes? Fast Food?.

Do you spend time in Nature or Fun? Beach _ Fishing _ Gol f_ Lakes _ Tennis _ Walking _Other_ What type of work do you perform? Work Schedule Are you a student? Y N Elementary Middle School High School College Highest leve l . Do you have many friends? What do you do with them? Do you vacation? Where? When last t ime? Do you visit the country or farms? When? When do you feel the best? Worst

FOODS/DRINKS • Artificial Sweeteners Crave Salt or Sugar Fast Foods, How Often

Pet or See Farm Animals Y N

Food Types Eaten Daily? Bread / Pasta / Fish / Red Meat / Fruie / Vegtables _ • Sweets How Often? Q Meals Eaten Per Day? Times in the Day. I I Energy Drinks How Of ten?. • Water How Much Dally? _

• Sodas Regular or Diet How Often?.

WOMEN O N L Y

V E S ^ NO 4 YES 4 m 4 yEs4 NO 4 1ES4 NO 4 YES 4 NO 4 \ES4 NO 4 Y E S d NO 4 Y E S ^ NO 4

Are you NOW pregnant? Are you having regular monthly menstrual cycles? If Yes Last cyc le? . If not, are you having symptoms of the menopause? Have you ever had bleeding between your cycles? When? Do you have very heavy bleeding with your cycles? When? Have you ever or do you now had any vaginal infections? When?_ Are you now or have you ever taken birth control pills? When? Do you now or ever and a hernia? Where? Surgery repai r?.

Date of last pap smear test How many? Children born alive?_ Any complications of pregnancy?_

Results . Miscarriages? Stlllblrths?_ C-Sections? Premature births?

MEN O N L Y

YES 4 NO Y E S ^ NO \ES4 NO Y E S ^ NO

A n y of your blood

Have you ever had problems with your testicles or scrotum? Have you ever had a discharge from your penis? Do you now or ever and a hernia? Where? Surgery repai r?.

4 Have you had trouble with your prostrate (urinary frequency, hesitancy, or dribble)? relatives have or had: Please circle all that apply ( i f yes, give date o f occurrence and relationship)

Stroke Rheumatic Heart Congenital Heart Colitis Hay Fever Migraine Asthma Diarrhea Bleeding Tendency Tuberculosis Blood Clots Pneumonia - i 'T : Bronchitis Thyroid Problems High Blood Pressure Cancer Seizures Bladder Infection Anxiety or Depression Heart Attack Diabetes Arthritis High Cholesterol Stomach Ulcers Kidney Disease Tonsillitis AIDSZ+HIV Heart Failure Glaucoma Gall Stones Leukemia Suicide Attempt

P A T I E N T ' S S I G N A T U R E D A T E

Doctor's Signature Date

CAROLYN DAYIS-WILLIAMS, D.C. - ADYANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax

REVIEW OF SYSTEMS PATIENT S NAME DATE CARDIOVASCULAR: • Angina • Ankle Swelling • Awakening At Night • Cardiac Catheterization • Chest Pains • Congenital Heart Defects • Cold Hands or Feet • Dizzy When Standing Quickly • Heart Attacks • Heart Failure • Heart Murmurs • Heart Palpitations • High Blood Pressure • Low Blood Pressure • Irregular Heart Rate • Leg Cramps • Leg Pain That Stop with Rest • Night Sweats • Pain Left Side Arm/Face/Neck • Pounding Heartbeat • Rapid Heartbeat • Purple Fingers or Lips • Short of Breath • Varicose Veins

EARS. & EYES. • Ear Aches • Ear Discharge • Ear Infections • Ear Pain • Hearing Loss • Ringing In Ears • Cataracts • Double Vision • Eye Problems • Glasses/Contacts • Glaucoma • Itchy, Red or Watery • Night Vision Poor • Pain In, Behind, Near

ENDOCRINE • Abnormal Blood Counts • Anemia • Arthritis • Changes In Skin Texture • Diabetes • Decrease/Increased Body Hair • Decrease/Increase Facial Hair • Decrease Head Hair (not male baldness) • History of "Borderline" Diabetes • Flushing / Hot Flashes • Intolerance Cold • Intolerance Heat O Sickle Cell

GASTROINTESTIONAL • Abdominal Pain • Anal Fissures • Belching • Intestinal Bloating •Gas/Flatulence • Black Tarry Stools •Const ipat ion • Diarrhea • Feel Fatigue or Lethargic After Eating • Gall Stones • Heart Burn • Hiatal Hernia • Hemorrhoids • indigestion • Intestinal Obstruction • Liver Disease • Loss of Bowel Control • Nausea • Pain in Stomach, Intestines or Colon • Poor Digestion • Problems Swallowing • Red Blood After Bowel Movement • Rectal Bleeding, Itching or Bleeding • Reflux • Ulcers • Vomiting Blood • Vomiting

GENERAL • Appetite Increased / Decreased • Binge/Compulsive Eating • Change in Activity • Change In Sleeping Patterns • Excessive Tiredness • Enlarged Lymph Nodes • Fatigue (lack of energy or stamina) • Frequent Infections • Hypoglycemia (Low Blood Sugar) • Increased Need tor Sleep • Insomnia • Tired or Not Hungry When Waking • Weight Gain • Weight Loss

KIDNEYS & URINARY TRACT • Bladder Problems • Blood In Urine • Brown Urine • Dribbling After Urination • Excessive Thirst • Frequent Bladder Intection • Involuntary Urination • Kidney Disease • Kidney Stones • Painful (or Burning) Urination

• Urination Frequency (Day) • Urination Frequency (Night) • Urine Hesitancy • Urinary Incontinence • Urinary Tract Infections (UTI) • Weak Flow

LUNGS • Asthma • Blood Clots in Lungs • Bronchitis • Coughing • Chest Congestion • COPD

MOUTH. NOSE. TEETH & THROAT • Decrease taste / smell • Gum Problems • Oral Herpes • Sores Mouth / Lips • Swollen / Tender Tongue / Gums • Swollen Glands • Allergies to Animals , Food , Environment/Chemicals • Hay Fever • Nose Bleeds Freq • Nasal Polyps • Nose Runs • Sinus Infections • Sinus Pain • Bad Breath • Dentures • Regular Dental Check-ups • Mercury fillings • Root Canals • Coughing • Drainage • Excess Mucus • Goiter • Hoarseness • Polyps • Sore Throats • Swollen Glands • Voice Changes MUSCULOSKELETAL • Areas of numbness • Areas of Pain • Areas of Tingling • Back Pain • Blood Clots in Legs • Bone Marrow Biopsy • Bursitis • Easy Bleeding • Easy Bruising • Gout • Joint Actios • Joint Pain • Joint Swelling • Limited Motion in Joints • Morning Stiffness • Muscle Aches/Pain • Muscle Weakness • Muscle Cramps • Neck Pain • Night Pain • Tendonitis

NEUROLOGICAL • Anxiety • Blackouts • Change in Sensation On Your Body • Contusion • Depression • Ditticult In Talking • Dizziness • Epilepsy • Fainting Spells • Headaches • Head injuries • Hyperactivity • Learning Difficulty • Loss of Consciousness • Memory Loss • Meningitis • Near Blackouts • Paralysis • Pressure feeling in Head • Seizures • Strokes • Tingling • Tremors • Weakness or Numbness

RESPIRATORY • Asthma • Breathlessness When Lying Flat • Coughing Up Blood • Emphysema • Frequent Bronchitis • Pleurisy • Pneumonia • Prolonged Cough • Shortness of Breath • Tuberculosis • Wheezing

SKIN & NAILS • Abscess • Acne • Athlete's Foot • Boils • Change in Skin Color • Dandruff • Dry Skin / Oily Skin • Eczema • Excessive Body Odor • Excessive / Not Sweating • Fungal Infections • Hives • Itchy Skin W or W/0 Redness • Jaundice • Lumps • Moles - Change • Moles - Irregular • Moles New • Psoriasis • Rashes • Small Rough Bumps on Skin • Nail Problems • Weak Nails • Ridged Nail

MALE & FEMALE • Genital Herpes • Groin Itching • Loss of Sexual Interest • Painful Sexual Intercourse • Sexually Transmitted Disease (STD) • Tested tor HIV Y N • Unprotected Sex

MALES ONLY • Bloody Ejaculation • Family History of Prostate Cancer Y N • Hernia • Inability to Complete Intercourse • Lump On Testicle • Penile Discharge • Problems Maintaining or Keeping Erection • Prostate Disease • Slow Urine Stream • Sores on Penis • Sterility • Testicular Pain • T e s t e s Undescended, In Abdomen or Pelvis • Testicular Swelling • Warts on Penis

FEMALES ONLY • Abnormal Bleeding Between Cycles • Abnormal PapTest • Bleeding After Intercourse • Complications With Pregnancy • D&C • Discharge From Breast • Endometriosis • Excessive Bleeding • Fibroids • Heavy Bleeding During Cycles • Hernia • Hot Flashes • Intertility • Irregular Periods • Pain in Breasts • Paintui Periods • Pain Between Periods • Ovarian Cyst • Pelvic Inflammatory Disease • Post-Menopausal Symptoms • (RMS) • Vaginal Discharge • Vaginal Dryness • Vaginal Warts • W a t e r Retention • Yeast Infections

Doctor's Signature Date

C A R O L Y N D A V I S - W I L I A M S , D . C . 2408 WHEELER ST. HOUSTON TX 77004

A D V A N C E D C H I R P R A C T I C C L I N I C , P . C . 713/529-6760 CLINIC 713/526-0655 FAX

Cl in ic 's Name, Address and phone Pat ien t Name: Ident i f icat ion Number : do not use Medicare # or S S #

ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE ( A B N ) NOTE: If Medicare doesn't pay for Spinal Manipulation below, you may have to pay.

Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. W e expect Medicare may not pay for the Spinal Manipulation below.

S p i n a l Manipulat ion 1 U N D E R S T A N D THAT MEDICARE D O E S NOT PA^ F O R EXAMINATIONS, T H E R A P I E S , S U P P L E M E N T OR S U P P L I E S P R O V I D E D BY A DOCTOR O F C H I R O P R A C T I C OR ANY MEDICAL T E S T I N G INCLUDING X - R A Y S AND BLOOD W O R K P R E S C R I B E D B Y A DOCTOR OF CHIROPRACTIC

(E) R e a s o n Med ica re May Not P a y :

• Medicare does NOT pay for Maintenance Care.

• Medicare does NOT pay for your diagnosis.

s • Medicare will NOT pay for more than 12 visits

per month.

. • Medicare will NOT pay for more than 30 visits

per year.

(F) E s t i m a t e d C o s t :

$ 3 5 - $ 4 5

$ 3 5 - $ 4 5

$ 3 5 - $ 4 5

$ 3 5 - $ 4 5

W H A T Y O U N E E D T O DO NOW:

R e a d this notice, so you can make an informed decision about your care. A s k us any questions that you may have after you finish reading. Choose an option below about whether to receive the Spinal Manipulation listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

(G) OPTIONS: C h e c k on ly o n e box . W e c a n n o t c h o o s e a box for y o u .

^ O P T I O N 1 . i want the Spinal Manipulation listed above. You may ask to be paid

now, but i also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN) , i understand that if Medicare doesn't pay, i am responsible for payment, but I c a n appea l to Med icare by following the directions on the M S N . if Medicare does pay, you will refund any payments i made to you, less co-pays or deductibles.

Ntsf O P T I O N 2 . i want the Spinal Manipulation listed above, but do not bill Medicare.

Y o u may ask to be paid now a s i am responsible for payment. I canno t appea l if Med i ca re i s not b i l led. "at O P T I O N 3 . i don't want the Spinal Manipulation listed above, i understand with this choice I a m not r espons ib l e for payment , and i cannot appeal to s e e if Medicare would pay.

(H) Add i t iona l In format ion: I DO NOT W A N T T O U S E MY M E D I C A R E

T h i s no t ice g i v e s our op in ion, not an of f ic ia l Med icare dec i s i on , if you have other quest ions on this notice or Medicare biiiing, call 1 - 8 0 0 - M E D I C A R E (1 -800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy.

(I) S i g n a t u r e : (J) Date:

According to the I'apervvork Reduclioii Act of 199.5, no persons arc icqnircd to respond to a collection of inCoimation unless it displays a valid 0 M B control number. I'lie x alid OMB conlrol number for tliis information collection is 0938-0566. The time rec|uiied to complete this informalion collection is estimated to average 7 minutes per respon.se, including the time to review instmction.s, search existing data resources, gather the d.ata needed, and complete and review the infoimation collection. I f you have comments concerning the accuracy of the time cstimalc or suggestions for improving this form, please write to: C M S . 7500 Security Boulevard, Attn: I'R.A Reports Clearance Olficer, Baltimore, Mawland 21244-1850.

F o r m C M S - R - 1 3 1 (03/08) ' Form Approved O M B No. 0938-0566

CAROLYN DAYIS-WILLIAMS, D.C. - ADYANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax

C H I R O P R A C T I C I N F O R M E D CONSENT

The doctor after examination has explained the prescribed treatment plan to me (for myself or for my minor child) including the nature and purpose of the chiropractic adjustments as well as other treatments or procedures appropriate for the condition. I hereby request and consent to treatment from ADVANCED CHIROPRACTIC CLINIC, P.C. doctors and staff including chiropractic adjustments, manual therapy techniques and physical modalities including hydroculation (heat), cryotherapy (ice), ultrasound, neuromuscular reeducation, massage, rehab, examinations or other treatments and testing that the doctor determines to he appropriate for my condition or for my minor child's condition.

In particular you should note: a) While rare, some patients have experienced rib fractures, muscle strains and/or ligament sprains following spinal

manipulation. h) There have been reported cases of injury to a vertebral artery following cervical spinal adjustments. Vertebral

artery injuries have been known to cause stroke, sometimes with serious neurological impairment, and may on rare occasion result in death.

c) Hydroculation (heat) and cyrotherapy (Ice): skin reactions or burns

Chiropractic treatments, including spinal adjustments, have been the subject of government reports and multi-disciplinary studies conducted over many years and have been demonstrated to he highly effective treatment for spinal pain, headaches being and other similar symptoms. The risk for injuries or complications from chiropractic treatment is substantially lower than that associated with many medical or other treatments, medications, and procedures given for the same symptoms.

I acknowledge I have discussed, or have had the opportunity to discuss, with my doctor the nature and purpose of the treatments in general and myself or my minor child's treatment in particular (including spinal adjustments) as well as the contents of this Consent and I fully understand that there are no guarantees in medicine as to the outcome of any treatment. I consent to the treatment offered or recommended to me for myself or my minor child including spinal adjustments. I intend this consent to apply to all of my or my minor child's present and future care.

I understand and am informed that, as with any medical treatment and care, in the practice of chiropractic there are some risks. I do not expect the doctor to he able to anticipate and explain all risks and complications. I wish to rely on the doctor to exercise judgment during the course of treatment and procedures that the doctor feels appropriate for me at the t ime based on the facts know at the t ime, in my or my minor child's best interest.

I have read (or have read to me) the above consent. I have had an opportunity to ask any questions I had about its content, and by signing below I agree to begin treatment for myself or for my minor child, _ .

I intend this consent form to cover the entire course of treatment for myself and/or my minor child's present condition and for any future condition (s) for which I may continue to seek treatment here at ADVANCED CHIROPRACTIC CLINIC, P.C.

Patient Printed Name Patient Signature Date

Witness Printed Name Witness Signature Date

Doctor's Signature Date

CAROLYN DAYIS-WILLIAMS, D.C. - ADYANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinie (713) 526-0655 Fax

H I P A A P O L I C I E S A N D P R O C E D U R E S

N E W P A T I E N T C O N S E N T T O T H E U S E A N D D I S C L O S U R E O F P R O T E C T E D H E A L T H I N F O R M A T I O N ( P H I ) F O R

T R E A T M E N T , P A Y M E N T O R H E A L T H C A R E O P E R A T O N S

I, , understand that as part of my health care, Carolyn Davis-Wllllams, D.C. - Advanced Chiropractic Clinic, P.C. originates and maintains paper and/or eiectronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment, i understand that this information serves as:

A basis for planning my care and treatment,

A means of communication among the many health professionals who contribute to my care,

A source of information for applying my diagnosis and surgical information to my bill

A means by which a third-party payer can verify that services billed were actually provided,

A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionais

i understand and have been provided with a Notice of information Practices that provides a more complete description of information uses and disclosures, i understand that i have the foiiowing rights and privileges:

The right to review the notice prior to signing this consent,

The right to object to the use of my health information for directory purposes, and

The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations

I understand that, Carolyn Davis-Williams, D.C. - Advanced Chiropractic Clinic, P.C. is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon, i also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that, Carolyn Davis-Wiiiiams, D.C. - Advanced Chiropractic Clinic, P.C. reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations.

I wish to have the foiiowing restrictions to the use or disclosure of my health information:

I understand that as part of this organization's treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and i consent to such disclosure for these permitted uses, including disclosures via fax.

I fully understand and accept / decline the terms of this consent.

Patient's Signature Patient Printed Name Date

Doctor's Signature Date

CAROLYN DAYIS-WILLIAMS, D.C. - ADYANCED CHIROPRACTIC CLINIC, PC 2408 Wheeler St. Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax

H I P A A P O L I C I E S A N D P R O C E D U R E S

H E A L T H C A R E A U T H O R I Z A T I O N F O R M

Patient's Name

Patients S S # Date of Birth

T H E P A T I E N T IDENTIF IED A B O V E A U T H O R I Z E S , C A R O L Y N DAVIS-WILLIAMS, D C. - ADVANCED C H I R O P R A C T I C CLINIC, P.C. T O U S E AND OR D I S C L O S E P R O T E C T E D HEALTH INFORMATION IN A C C O R D A N C E WITH T H E FOLLOWING:

S P E C I F I C A U T H O R I Z A T I O N S

• I give permission to C A R O L Y N DAVIS-WILLIAMS, D.C. - ADVANCED C H I R O P R A C T I G CLINIC, P.C. to use my address, phone number and clinical records to contact me with birthday cards, emails, holiday related cards and information about treatment alternatives or other health related information.

O P E N R O O M A U T H O R I Z A T I O N

• i give C A R O L Y N DAVIS-WILLIAMS, D.C. - ADVANCED C H I R O P R A C T I C CLINIC, P.C. permission to treat me in an open room where other patients are also being treated. 1 am aware that other persons in the office may overhear some of my protected health information during the course of care. Should i need to speak with doctor at any time in private; the doctor will provide a room for these conversations.

• By signing this form you are giving C A R O L Y N DAVIS-WILLIAMS, D.C. - ADVANCED C H I R C P R A C T I C CLINIC, P.C. permission to use and disclose your protected health information in accordance with the directives listed above.

E X P I R A T I O N

The Authorization shall expire on the following date:

R I G H T T O R E V O K E A U T H O R I Z A T I O N

You have the right to revoke this AUTHORIZATION, in writing, at any time. However, your written request to revoke this AUTHORIZATION is not effective to the extent that we have provided services or taken action in reliance on your authorization. You may revoke this AUTHORIZATION by mailing or hand delivering a written notice to the Privacy Official of C A R O L Y N DAVIS-WILLIAMS, D.C. - ADVANCED C H I R C P R A C T i C CLINiC, P.C. A clear statement of your intent to revoke this AUTHORIZATION; requires the date of your request, your signature and the revocation is not effective until it is received by the Privacy Official. This AUTHORIZATION is requested by CAROLYN DAVIS-WILLIAMS, D.C. -ADVANCED C H i R C P R A C T i C CLINiC, P.C. for its own use/disclosure of PHI. You have the right to refuse to sign this AUTHORIZATION. If you refuse to sign this AUTHORIZATION, C A R O L Y N DAVIS-WILLIAMS, D.C. - ADVANCED C H i R C P R A C T i C CLINIC, P.C. will not refuse to provide treatment. You have the right to inspect or copy the PHI to be used/disclosed.

Name of Patient Signature of Patient Date

Name of Guardian if Patient is a Minor Signature of Guardian if Patient is a Minor Date

Doctor's Signature Date

CAROLYN DAYIS-WILLIAMS, D.C. - ADYANCED CHIROPRACTIC C L I N I C , PC 2408 Wheeler St Houston, T X 77004 (713) 529-6760 Clinic (713) 526-0655 Fax

H I P A A P O L I C I E S A N D P R O C E D U R E S

ACKNOWLEDGEMENT OF R E C E I P T OF NOTICE OF PRIYACY P R A C T I C E S

I , , understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

• T h e right to rev iew the notice prior to signing this consent , • T h e right to object to the use of my heal th informat ion for directory purposes, and

• T h e right to request restr ict ions as to how my heal th informat ion may be used or d isc losed to carry out t r ea tmen t , payment , or heal th care operat ions

Patient Printed Name Patient Signature Date

[ ] Consent rece ived by on [ ] Consent added to the pat ient 's medical record on

At tempt w a s made to obtain wr i t ten acknowledgement of receipt of out Notice of Pr ivacy Pract ices, but acknowledgement could not be obtained due to: [ ] Consent re fused by pat ient t rea tmen t w a s rendered . [ ] Consent re fused by patient, and t rea tment refused as permi t ted. [ ] Communica t ion barr ier prohibited the acknowledgment . [ ] Emergency si tuat ion prevented obtaining acknowledgment . [ ] Other speci fy si tuat ion

Staff Printed Name Staff Signature Date

Doctor's Signature Date