I have received, and read, the Professional Physical Therapy & Sports Medicine Patient Authorization and Guarantee.  I understand all guarantees and financial policies as expressed in the document.

Patient's Name:  {legalName}

Patient Name:  {legalName}

Patient Date of Birth:  {dateOf341}

Patient Address:  {address4}

When my information is used or disclosed as described in this authorization, I understand that it may be subject to disclosure by the persons listed above and may no longer be protected by the federal HIPPA Privacy Rule.

I have the right to revoke this authorization in writing except to the extent that Professional Physical Therapy & Sports Medicine has already acted in accordance with this authorization.  My written revocation must be submitted to Professional Physical Therapy & Sports Medicine Privacy Official at 620 Old West Central Street, Franklin, MA 02038.