Consent for Treatment
Permission to Use Photograph and/or Video
Assignment of Benefits and Insurance Proceeds
Release of Information
Designated Persons Authorization
I, the undersigned, hereby authorize one or all of the designated parties below to request and receive the release of any protected health information regarding my treatment, payment or administrative operations related to treatment and payment. I understand that the identity of designated parties will be verified by photo ID before the release of any information. If none, leave blank.
Patient Privacy Consent Form (HIPAA)
I have read and fully understand BUILD PHYSIO & PERFORMANCE, PLLC’s Notice of Privacy Practices (HIPAA). I understand that BUILD PHYSIO & PERFORMANCE, PLLC may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of service provided, and any administrative operations related to treatment or payment. I understand that I have the right to request restrictions, in writing, regarding how my personal health information is used and disclosed for treatment, payment, and administrative operations. I also understand that BUILD PHYSIO & PERFORMANCE, PLLC will consider requests for restrictions on a case by case basis, but is not required to oblige to such requests.
I hereby consent to the use and disclosure of my personal health information for purposes as noted in BUILD PHYSIO & PERFORMANCE, PLLC’s Notice of Privacy Practices (HIPAA). I understand that I retain the right to revoke this consent by notifying the practice in writing at any time, at which point BUILD PHYSIO & PERFORMANCE, PLLC has 30 days to respond to my request.