HIPPA Consent Form

HIPPA Consent Form
I give Consent to Comerstone Therapy Services, Inc staff to disclose Protected Health Information (PHI) regarding my child's therapy process in the common areas of Cormerstone Therapy Services, Inc. I have the right to revoke this consent at any time via written notice.

Signature (Do not sign if you would like to speak in private)
Persons, who may accompany minor, make decisions and may obtain child therapy Information.
Name

First NameLast Name
Relationship:
Name

First NameLast Name
Relationship:
Name

First NameLast Name
Relationship:
Child's Name:
Parent/ Guardian Name:
Signature
Date

MonthDayYear
Date
Should be Empty: