Patient Notification Policy

In compliance with the Health Insurance Portability and Accountability Act (“HIPAA”) Privacy Rule and our Notice of Privacy Practices, Movement Restoration will not disclose your protected health information (“PHI”) without your explicit authorization, except as permitted by law for the purposes of payment, treatment and health care operations. Furthermore, Movement Restoration will limit the use, disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. Therefore, Movement Restoration will only disclose your appointment information, such as reminders or cancellations, on an answering machine, voice mail, text message or e-mail, unless you inform us otherwise. This notice refers to Movement Restoration as “us” and “our,” and to the patient/guardian as “I,” “my,” “you,” “your,” and “yourself.”

I, the undersigned, hereby authorize Movement Restoration to disclose my appointment information by the following methods of communication and I assume all responsibility for ensuring that the methods of communication that I indicated below are secure, with password protection used where applicable: (Sign with fingertip or mouse).

Name

First NameLast Name

Date

Please indicate type(s) of preferred communication:

Phone CallText MessageVoice MailE-Mail

If you choose to have your PHI communicated to individuals other than yourself, please accurately complete the information below and sign the authorization. I further agree to be responsible for notifying Movement Restoration if any of the foregoing change.

I, the undersigned, hereby authorize Movement Restoration to disclose my PHI to the person(s) named below. This is not required. (Sign with fingertip or mouse).

Name

First NameLast Name

Date

1st Contact

First NameLast Name

1st Contact Phone Number

Area CodePhone Number

2nd Contact

First NameLast Name

2nd Contact Phone Number

Area CodePhone Number