I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPPA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly.
- Obtain payment from third-party payers
- Conduct normal healthcare operations such as quality assessments and physician certifications.
I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Private Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide in such restrictions.
I authorize my insurer to pay any benefits for services rendered directly to Physical Therapy Associates. I understand that anything not covered by insurance is my full responsibility. I hereby authorize Physical Therapy Associates through it’s appropriate personnel to perform on me, or the patient named above, appropriate assessment and treatment procedures relating to my diagnosis.