HIPAA/Informed Consent Form

HIPAA/Informed Consent Form
Patient Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Please choose one:*

I am the patient, am over 18, and am completing the form myself.The patient is a minor and this form is being completed by a parent/guardian.
This form is being signed by*
Relationship to patient*
Email*
example@example.com
1. INFORMED CONSENT FOR EVALUATION AND TREATMENT

I hereby consent to evaluation and treatment by a licensed/credentialed provider through Carolina Dancer Wellness in the following disciplines. I confirm that I have been provided with links to and/or downloads of the informed consent paperwork. I have read and fully understand the consent forms for the disciplines indicated above. In the event of a change in medical status, I understand that my treatment may be modified, stopped, or referred out to the proper practitioner. I have been given on opportunity to ask questions, and all my questions have been answered to my satisfaction. I reserve the right to withdraw at any time.

View Consent/Disclosure Forms Here
(Please indicate below)*

Physical TherapyStrength/ConditioningMassageMental Health CounselingMental Performance CoachingNutrition Counseling
Signature*

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2. PATIENT INFORMATION CONSENT FORM (HIPAA)

The patient understands that: Protected health information may be disclosed or used for treatment, payment, or health care operations. The Practice has Notice of Privacy Practices and that the patient has the opportunity to review this Notice. The practice reserves the right to change the Notice of Privacy Practices. The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions. The patient may revoke this Consent in writing at any time and all future disclosures will then cease. The Practice may condition receipt of treatment upon the execution of this Consent.
Signature*

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3. CANCELLATION AND PAYMENT POLICIES

Cancellation

We value your time as our patient. We hope that you will also value the time of our therapists by calling, texting, or emailing our office if there is a reason that you are unable to keep your appointment. Cancellations are requested within 24 hours of your appointment. If you fail to come to your appointments, the following policy is enforced:

• First No-Show/late cancellation: You will receive a phone call or text informing you that you missed the scheduled appointment.

• Second No-Show/late cancellation: You will receive notification that two (2) appointments have now been missed without notifying the office within the appropriate time frame and you will be charged a $25.00 fee.

• Third No-Show/late cancellation: You will receive notification regarding your no-show history and you will be charged the full individual appointment self-pay rate.

Excessive last-minute cancellations will be subject to a $25.00 fee per appointment cancellation not received 24 hours in advance. Last-minute cancellations less than 6 hours in advance may subject to the full appointment fee.

Payment

Patients with an insurance co-payment are expected to pay the co-pay at the time of service.

Patients opting for self-pay may pay at the time of service, purchase a discounted pre-paid package, or pay for multiple visits in one bill that will be issued in the billing cycle after the time of service. Payment is expected within 30 days of the end of the billing cycle. Late payments are subject to a 5% late fee each month they are late. Financial aid and payment plans are available upon request.
Signature*

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4. Electronic Communication (Text and Email)

Many patients prefer to communicate via text and email for appointment reminders, billing statements, and for general questions about their treatment programs. Please note that this form of electronic communication is never absolutely secure texts, emails, and billings statements may contain health information.
Do you consent to receiving electronic communication (texts and emails) from our office?*

YesNo
5. RELEASE OF INFORMATION

I hereby authorize the designated parties below to received protected health information regarding dance recommendations/modifications, treatment, or administrative operations related to my course of treatment.

Parents/Guardians of minors do not have to be listed below to receive information about their child.
Do you want us to communicate with your studio/company about your treatment and dance recommendations/modifications?*

YesNo
Please indicate the name of the studio and/or individuals you would like to share information with.*
Please list the names and relationship to the patient of other medical providers or individuals with whom you wish us to share information.
6. PHOTO RELEASE

We occasionally share images of dancers who are examples of good technique and making progress towards goals to help encourage and educate other dancers. Options are available to be included on our social media (website, Facebook and Instagram), as part of home exercise programs, or educational programs.
May we include you/your dancer in our media?*

Yes (Individual selections are available on next page)No
7. DANCE MEDICINE RESEARCH

Carolina Dancer Wellness performs research studies in the field of dance medicine in areas such as: understanding patterns of dance injury in dancers, developing preventative practices, optimizing performance outcomes, and improving recovery from injury. To assist in this research, we ask clients for permission to collect data pertinent to these research projects. All data collected and used in research will be anonymized and individual patient identifiers (name, birth date, etc) will be hidden to protect patient privacy. The data that we collect may include, but is not limited to, parameters such as: age, height, physical performance (strength, range of motion, etc), injury patterns, and opinion surveys.

A description of current research projects can be found on our website.
May we include you/your dancer in our research projects?*

Yes, I consent to the Carolina Dancer Wellness research team to use my de-identified/anonymized health information for the purposes of dance medicine research. I understand that I may revoke this permission at any time.No, I do not consent for Carolina Dancer Wellness to use my health information for research purposes.

Photo Release Form
By consenting to the release of images to Carolina Dancer Wellness, I understand that:

Images may be used in educational materials, social media (Facebook, Instagram, website, etc), and online and printed marketing materials.
No compensation is expected, in cash or in kind.
Subject's names will not be included in the images for exercise demonstration. Names may occasionally be included for website, Facebook, and Instagram posts, but only if permission is given below.
Your consent or refusal to consent to the release of your photographs will not, in any way affect the services you receive from our company.
You may rescind your authorization to the release of the photographs by submitting a request in writing.

I hereby grant the Carolina Dancer Wellness and its agents permission to use photographs, digital images of me, or in which I may be included in whole or part, for the purposes indicated below.
Please indicate your preference*

My name may be included for website, Facebook, and Instagram posts, etcPlease do not include my name with any photos
Signature*

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Should be Empty:

HIPAA/Informed Consent Form

Photo Release Form