Please provide the available days and times for therapy sessions. This will help us schedule appointments that work best for you. 

Por favor, indique los días y horas disponibles para las sesiones de terapia. Esto nos ayudará a programar citas que se adapten mejor a usted.

Acknowledgment

I acknowledge that the services my child will be receiving cannot be rendered simultaneously with any other treatments or services. By signing below, I confirm that I have read and understood this statement.

Reconocimiento

Reconozco que los servicios que mi hija/hijo recibirá no pueden ser brindados simultáneamente con ningún otro tratamiento o servicio. Al firmar a continuación, confirmo que he leído y comprendido esta declaración.

Do your best to answer the following questions, but only the questions with a red star * are required. If you do not know an answer, it is ok to leave the question blank.

Haga todo lo posible para responder las siguientes preguntas, pero solo las preguntas con una estrella roja * son obligatorias. Si no sabe una respuesta, puede dejar la pregunta en blanco.

How old was the child when they:

¿Qué edad tenía el niño cuando:

This permission is allowed while the above name child is at Optimize Today's Wellness Therapy Solutions office, school, daycare center, home, family member's home/any area that the undersigned leaves the child during the time of the child's appointment with Optimize Today's Wellness Therapy Solutions Inc., concerning the care and treatment of the above named child.

I further give permission to Optimize Today's Wellness Therapy Solutions, Inc. to communicate with their child's physician, related health professionals, school officials, teachers, parents, family members as deemed fit in the sole discretions of Optimize Today's Wellness Therapy Solutions, Inc. concerning the care and treatment of the above named child.

By Signing the following, I hereby agree to have listed both Primary and Secondary insurances (If applicable) Failure to comply, may result in charges and penalties not covered by the insurance.

At Optimize Today's Wellness Therapy Solutions, Inc., we are committed to protecting your privacy and maintaining the confidentiality of your personal health information. This Notice of Privacy Practices explains how we may use and disclose your health information and your rights regarding your health information under the Health Insurance Portability and Accountability Act (HIPAA) and applicable laws in the state of Florida.

Our Responsibilities:

We are required by law to:

• Maintain the privacy of your health information.
• Provide you with this Notice of Privacy Practices.
• Follow the terms of this Notice.

Uses and Disclosures of Health Information:

We may use and disclose your health information for the following purposes:

• Treatment: We may use and disclose your health information to provide you with medical treatment and services.
• Payment: We may use and disclose your health information to bill and collect payment for the treatment and services provided to you.
• Healthcare Operations: We may use and disclose your health information for our healthcare operations, such as quality improvement and business management.
• Appointment Reminders: We may contact you to provide appointment reminders.
• Treatment Alternatives: We may use and disclose your health information to inform you about treatment alternatives or health-related benefits and services.
• Required by Law: We may use and disclose your health information when required by law.
• Public Health: We may disclose your health information for public health activities.
• Law Enforcement: We may disclose your health information for law enforcement purposes.
• Health Oversight: We may disclose your health information for health oversight activities.
• Special Situations: We may use or disclose your health information for certain special situations, such as organ and tissue donation or to prevent a serious threat to health or safety.

Your Rights:

You have the following rights regarding your health information:

• Right to Inspect and Copy: You may request access to your health information and receive a copy of it.
• Right to Amend: You may request to amend your health information if you believe it is incorrect or incomplete.
• Right to an Accounting of Disclosures: You may request a list of disclosures of your health information that we have made.
• Right to Request Restrictions: You may request restrictions on certain uses and disclosures of your health information.
• Right to Request Confidential Communications: You may request to receive communications of your health information by alternative means or at alternative locations.
• Right to a Paper Copy of this Notice: You may request a paper copy of this Notice of Privacy Practices.

Our Contact Information:

If you have any questions, concerns, or wish to exercise your rights, please contact us at info@otwellness4u.com.

Consent:

I hereby acknowledge that I have received a copy of Optimize Today's Wellness Therapy Solutions, Inc.'s Notice of Privacy Practices. I understand the uses and disclosures of my health information as described in the Notice. I acknowledge that I have the right to request restrictions on the use and disclosure of my health information. I understand that I have the right to revoke this consent in writing at any time, except to the extent that action has been taken in reliance on it. I understand that my healthcare treatment and payment for treatment are not conditioned upon my signing this consent.

Photo/Video Release - Parental Consent Form

I hereby grant permission to Optimize Today's Wellness Therapy Solutions, Inc. and its representatives to photograph, videotape, and record my child/ward, during their participation in activities related to the organization. I understand and agree to the terms outlined below:

1. Consent: I grant Optimize Today's Wellness Therapy Solutions, Inc. the right to use, reproduce, distribute, and publicly display any photographs, videos, or recordings of my child/ward for promotional, educational, or informational purposes, including but not limited to brochures, websites, social media, presentations, and advertisements.

2. Release: I release Optimize Today's Wellness Therapy Solutions, Inc., its employees, representatives, and any third parties acting under its authority, from any liability, claims, demands, actions, causes of action, costs, and expenses arising out of the use, reproduction, distribution, and display of the photographs, videos, or recordings of my child/ward.

3. Ownership: I acknowledge that all rights to the photographs, videos, and recordings shall belong to Optimize Today's Wellness Therapy Solutions, Inc., and I waive any right to inspect or approve the final products before they are published or distributed.

4. Compensation: I understand that my child/ward will not receive any compensation for the use of the photographs, videos, or recordings.

5. Confidentiality: I acknowledge that any information that can be personally identified in the photographs, videos, or recordings may be disclosed in accordance with the Notice of Privacy Practices of Optimize Today's Wellness Therapy Solutions, Inc.

6. Duration: This release shall remain in effect indefinitely unless I revoke it in writing.

Consent:

By signing below, I confirm that I have read and understood the terms of this Photo/Video Release - Parental Consent Form and agree to its contents.

I hereby consent to the terms of the Photo/Video Release - Parental Consent Form on behalf of my child/ward.