Patient Forms

We offer our patient forms online so they can be completed in the convenience of your own home or office before you arrive for your appointment

  • If you do not already have AdobeReaderĀ® installed on your computer, click here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Bring your completed form(s) with you to your appointment.

Patient Intake Forms

Informed Consent

HIPAA


HIPAA Compliance

Bruno Da Rocha DC, CCSP
2100 East Hallandale Beach Blvd, Office 205
Hallandale Beach, FL 33009
Telephone: (305) 497-2821
Email: [email protected]
Website: www.drdarocha.com


Chiropractic Informed Consent To Treat

We may use and disclose your PHI (private health information) in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We may also disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute.

We may use or disclose your PHI for workers compensation and similar programs.

We may contact you by mail or phone, at your residence, to remind you of appointments or to provide information about treatment alternatives. Unless you instruct us otherwise, we may mail you a postcard reminding you to make an appointment and we may leave a message for you on any answering device or with any person who answers the phone at your residence.

You can make a reasonable request for us to use alternative methods of communicating with you in a confidential manner. These requests must be submitted in writing in a clear and concise fashion. We are not required to agree to your request. However, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when information is necessary to treat you.

Rights that you have: You have the right to request restrictions on some of the uses or disclosures described above. Except as stated, we are not required to agree to such restrictions.

You have the right to inspect and obtain copies of your medical Information. (A fee for the costs of copying, mailing, labor and supplies associated with your request will be charged.)

You have the right to request amendments to your medical information. Such requests must be in writing, and must state the reason for the requested amendment. We will notify you as to whether we agree or disagree with the requested amendment. If we disagree with any requested amendment, we will further notify you of your rights.

You have the right to request an accounting of any disclosure we make of your medical information except for disclosures we make to you, to carry out treatment, payment or healthcare operations, as requested by your written authorization, as permitted or required under 45 CFR 164.502, for emergency or notification purposes, for national security or Intelligence purposes as permitted by law, or to correctional facilities or law enforcement officials as permitted by law.

You have the right to receive a paper copy of this notice. To obtain a paper copy of this notice, please contact our office manager. our office manager.

You have the right to file a complaint if you believe your privacy rights have been violated. You may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing and addressed to this office at the above address. You will not be penalized for filing a complaint.

This privacy policy is subject to change as circumstances dictate. Any changes will be effective upon the release of a revised privacy policy, which will be made available to patients upon request.

Contact Us Today!

We look forward to hearing from you.

Our Location

2100 East Hallandale Beach Blvd #205 | Hallandale Beach, FL 33009

Office Hours

Our General Schedule

Monday:

10:00 am-7:00 pm

Tuesday:

10:00 am-7:00 pm

Wednesday:

10:00 am-7:00 pm

Thursday:

10:00 am-7:00 pm

Friday:

10:00 am-7:00 pm

Saturday:

9:00 am-1:00 pm

Sunday:

Closed