I hereby authorize the specific personnel/healthcare facility to gather all the necessary details needed for my appointment to ensure the safety of both the patient and the therapist.

I understand that my personal health information is subject to disclosure by the facility receiving it for legal purposes.

I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice.

 I authorize my insurance benefits to be charged directly the facility and that I am responsible for any cost in any case my insurance claim be denied.