Patient Consent Form - Hansen Physical Therapy, PLLC

PATIENT CONSENT FORM for USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

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  • PATIENT CONSENT FORM for USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

  • I hereby give my consent to Hansen Physical Therapy, PLLC to send physical therapy notes, and to discuss information regarding myself or my child, to my primary and referring physicians, my authorized representative, my case manager and my insurance companies. I also understand that my health information may be used to carry out my care and treatment, to obtain payment, and for this organization's health care operations.

    As a patient/client, you have the right to request that Hansen Physical Therapy, PLLC restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement. We require that this request be put in writing.

    A more complete description of uses and disclosures is in Pelvic Health's 'Notice of Health Information Packet' which is on page three of this document.

  • By typing your name in the space below you are providing an "electronic signature" and it indicates your approval of the information contained in this electronic form.
    (This consent expires two years from the date it was signed)
  • Date Format: MM slash DD slash YYYY