5 HIPAA Patient Consent Form copy

HIPAA Patient consent form
Patient Consent for Use and Disclosure of Protected Health Information
I hereby give my consent for Mann Method Physical Therapy and Fitness, LLC to use
and disclose protected health information (PHI) about me to carry out treatment, payment
and health care operations (TPO). (The Notice of Privacy Practices provided by Mann
Method Physical Therapy and Fitness, LLC describes such uses and disclosures.)
• I have the right to review the Notice of Privacy Practices prior to signing this consent. Mann
Method Physical Therapy and Fitness, LLC reserves the right to revise its Notice of
Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by
forwarding a written request to
o Mann Method Physical Therapy and Fitness, LLC
o Sarah Mann, PT, DPT, MBA, NSCA-CPT, 8081 East Orchard Road, Suite 215,
Greenwood Village, CO 80113, 303.709.6381, [email protected]
• With this consent, Mann Method Physical Therapy and Fitness, LLC may call my home
or other alternative location and leave a message on voice mail or in person in reference to
any items that assist the practice in carrying out TPO, such as appointment reminders,
insurance items and any calls pertaining to my clinical care.
• With this consent, Mann Method Physical Therapy and Fitness, LLC may mail to my
home or other alternative location any items that assist the practice in carrying out TPO, such
as appointment reminder cards and patient statements as long as they are marked “Personal
and Confidential.”
• With this consent, Mann Method Physical Therapy and Fitness, LLC may e-mail to my
home or other alternative location any items that assist the practice in carrying out TPO, such
as appointment reminder cards and patient statements. I have the right to request that Mann
Method Physical Therapy and Fitness, LLC restrict how it uses or discloses my PHI to
carry out TPO. The practice is not required to agree to my requested restrictions, but if it
does, it is bound by this agreement.
• By signing this form, I am consenting to allow Mann Method Physical Therapy and
Fitness, LLC to use and disclose my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made
disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it,
Mann Method Physical Therapy and Fitness, LLC may decline to provide treatment to me.
•
_______________________________
Signature of Patient or Legal Guardian
_______________________________
Print Patient’s Name
______________________
Date
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Print Name of Patient or Legal Guardian, if applicable