Providers who do not “opt-out” of ChiroUp Outcome Tracker may need to modify their Notice of Privacy Practices (NPP) to disclose that they will be sharing PHI and requesting online reviews. The following is only a sample of the language used for that purpose. ChiroUp is not a legal resource. We do not warrant the following verbiage and suggest consulting with a healthcare attorney to make sure that any language meets the requirements for your application.

“I acknowledge and understand that this office may contact and survey me via e-mail regarding my satisfaction and outcomes. I understand that an independent vendor(s) may assist with this data collection. I understand that in addition to the aforementioned confidential survey, this office or their designated vendor may also send an automated email to allow me to voluntarily and publicly rate and review my provider online through sites like; Google Review, HealthGrades, Yelp, etc. I acknowledge that my responses, like other online responses, may be published on the respective review site(s) and will be publicly disclosed and accessible to anyone who accesses that site. I understand that reviews are optional, and I am under no obligation to provide a review. I also understand that if I do choose to provide a review, I will not include any sensitive, personal, identifying, or medical information that I do not wish to be publicly disclosed in an online review, including but not limited to: name, contact information, social security number, health history, diagnosis, medications, etc. I understand, acknowledge, and agree that if I include Protected Health Information, I am doing so voluntarily and with full knowledge and intent. When submitting a survey or review, I agree to fully release, waive and indemnify this office and/or the associated vendors from any and all claims arising from my voluntary disclosure of Protected Health Information to the sites.”