Our practice is required by law to maintain the privacy of your health information. We are dedicated to maintaining the confidentiality of your health information.
1. I understand that I have the right to ask and have any questions answered prior to receiving treatment, including any risks or alternatives to the treatment plan that has been prescribed by me. By signing below, I consent to have a therapist employed at Jodi Gilray PT, PLLC provide treatment. Should I be unable to bring my child in for therapy, a signed release to have a friend/family member bring child in will serve as my consent to treat.
2. Jodi Gilray PT, PLLC and its employees/contractors are authorized to use or disclose health information that is pertinent or required for therapy purposes. I have a right to a paper copy of the Notice of Privacy Practices at any time.
3. I understand that Jodi Gilray PT, PLLC may be disclosing protected health information to a patient's insurance company and physician for continuing care. I also understand that the information used or disclosed may be subject to multiple disclosures by the individual or facility receiving the information. Upon written request, I have a right to a copy of my child's health information, including medical records and billing records and may be charged the reasonable cost based fee imposed by Jodi Gilray PT, PLLC.
4. I may revoke the authorization by notifying Jodi Gilray PT, PLLC in writing. However, I understand that any action taken previously to revocation of this authorization cannot be reversed, and my revocation will not affect those actions. The authorization expires when a patient is discharged by Jodi Gilray PT, PLLC or when written notice to revoke authorization is received. Prior notification will be given to the parent or guardian before information is released.
5. I do hereby give my consent for speech, occupational and physical therapy at Jodi Gilray PT, PLLC according to the guidelines established by the referring physician and the therapist. In doing so, I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily contact, touching and/or direct contact.
6. I, as parent/guardian of minor receiving treatment, do hereby agree and understand that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resulting from failure to do so.
7. I know and agree that Jodi Gilray PT, PLLC is not responsible for loss or damage of personal valuables.
8.Health Care Operations. Our practice may use and disclose your medical information to operate our business. These uses and disclosures are important to ensure that you receive quality care and that our practice is well run. As examples, we may use and disclose information via credit card processing or online medical scribes to conduct operational, cost-management and business planning activities for our practice. Further we may disclose your information to doctors, nurses, medical students and other personnel for continuity of patient care purposes.