HIPAA COMPLIANCE PRIVACY STATEMENT

I understand that under the Health Insurance Portability & Accountability Act (HIPAA), I have certain rights related to protecting my personal health information.  I understand that my personal information will be used to:

• Help manage and administer the health care treatment received
• Run the organization
• Share information about your treatment with your referring healthcare provider, and other healthcare providers who would be assisting in providing care related to your treatment with our organization
• Populate records in our scheduling, patient records, billing, and other specialized software packages needed in order to manage the administrative side of your treatment
• Obtain payment for rendered health services
• Do research
• Comply with the law
• Address workers’ compensation, law enforcement, and other government requests (if applicable)
• Respond to lawsuits and legal actions (if applicable)

I acknowledge that I received, read, and understand the NOTICE OF PRIVACY PRACTICES which contains a thorough description of the uses and disclosures of my private health information.

PATIENT ACKNOWLEDGEMENT AND AUTHORIZATION OF RELEASE

The above information is true to the best of my knowledge. I authorize Family Physical Therapy and Wellness, LLC to apply for insurance benefits on my behalf. I understand that I am financially responsible for any balance. I also authorize Family Physical Therapy and Wellness, LLC or my insurance company(ies) to release any information required to process my claims.

CONSENT TO TREATMENT

I consent to receive outpatient Physical Therapy services for myself (or my child) and any ancillary services that are deemed medically necessary or appropriate by my physical therapist.

MEDICAL AND BILLING INFORMATION RELEASE

Dependent Patient Billing – Please send the billing statements to the following address:

CONSENT TO E-MAIL OR PHONE FOR APPOINTMENT REMINDERS AND OTHER COMMUNICATIONS

Patients in our practice may be contacted via email and/or phone to remind them of appointments and/or provide general information related to Family Physical Therapy and Wellness, LLC. By signing below, you consent to receive communications at the email address and phone number provided in the patient registration form. We will not share your email and phone number with any other parties. Please indiciate your preference: