Second Opinion Spine Care
Subsidiary of WellConsulted, LLC.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

In the course of your care as a client with Second Opinion Spine Care (Subsidiary of Wellconsulted, LLC), we may use or disclose personal and health related information about you in the following ways:

*Your personal health information, including of your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.  

*Your name, address, phone number, email and your health care records may be used to contact you regarding information about alternatives to your present care, or other health related information that may be of interest to you via mail/email.

If you are not at home a message may be left on your voice mail or an email or a text message may be sent.  Further, you have the right to inspect or obtain a copy of the information we will use for these purposes. You also have the right to refuse to provide authorization for this office to contact you regarding these matters. If you do not provide us with this authorization it will not affect the care provide to you or the reimbursement avenues associated with your care.

Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in these following circumstances:


*If we are providing health care services to you based on the orders of another health care provider.
*If we provide health care services to you in an emergency.
*If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so.
*If there are substantial barriers to communicating with you, but in our professional judgement we believe that you intend for us to provide information to next of kin.
*If we are ordered by the courts or another appropriate agency

Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization.

We may also mail/email information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than the one provided to us by you or if you would like the information in a different form please advise us in writing as to your preferences.

You have the right to inspect and/or copy your health information for seven years from the date that the record was created or as long as the information remains in our files. In addition you have the right to request an amendment to your health information. Requests to inspect, copy or amend your health related information should be provided to us in writing.

We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information.

We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all of your health information in our files.

Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.

If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to:

Dr. John Friedrichs, D.C.
CEO WellConsulted, LLC                    

If you would like further information about our privacy policies and practices please contact: Dr. Friedrichs, D.C.

This notice is effective as of June 1, 2016.  This notice, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created. My signature acknowledges that I have received a copy of this notice.


____________________________      ___________________________________   ___________________________________  
Name  (Printed please)                          Signature                                              Date               


​I attest the information provided above is true and represents to most recent facts regarding my current health status. I give authorization to Second Opinion Spine Care (as subsidiary of WellConsulted, LLC) to review this confidential health history and questionnaire. I authorize Second Opinion Spine Care to provide me with a second opinion on a recommended treatment for my current health status based solely on this questionnaire and X-rays or MRIs that I have submitted to Second Opinion Spine Care. I also understand that this second opinion does not in any way replace or attempt to replace a person to person in person physical examination with my current physician or any other physician or doctor. This second opinion I am requesting is simply an opinion for suggested treatment options based on information provided via the internet. I am aware that any information I receive from Second Opinion Spine Care is to be reviewed and discussed with my personal physician, care taker and or other doctor whom I have direct in person contact with. I am also over the age of 18 and I am of sound mind.  No Refunds will be provided.


____________________________      ___________________________________   ___________________________________  
Name  (Printed please)                          Signature                                              Date               


Disclaimer:  This service should be used for additional reviews and opinion only.  This service does not intend to replace any diagnosis, treatment plan or prescription provided to you by your physician, doctor or other care taker you are currently or have in the past consulted with regarding your health diagnosis and treatment. Our doctors provide opinions, not diagnosis' or treatment plans.  All opinions provided are to be shared with and consulted with your primary doctor in person to determine your best avenue of treatment to improve your health.  This services does not replace or attempt to establish any patient-doctor relationship.  This service provides non-biased opinions on options for spinal care based off X-ray or MRI reports submitted to Second Opinion Spine Care.   This service does not replace in person consultation and or physical examination, which must be sought out individually with your personal physician or doctor of choice.


​Terms & conditions