HIPAA Privacy Statement – Pediatric Therapy Services

HIPAA- Privacy Statement

Office Location*
Please select your correct location for each form.
I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.
- Obtain payment from third-party payers
- Conduct normal healthcare operations such as quality assessments and physician certifications
I received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI. I understand that this organization has the right to change its Notice of Practices from time to time and that I may contact this organization at any time to obtain a current copy of Notice of Privacy Practices.
Patient First Name*
Patient Last Name*
Email*
Signature*
Date*
Month
Day
Year

READY FOR A FUN THERAPY ENVIRONMENT,
THAT TRULY CARES ABOUT YOUR CHILD AND YOUR FAMILY?

If you are interested in enrolling your child in the intensive strengthening program at PTS, please utilize the links below to complete the intake documents. Once your intake documents are received, you will receive a phone call to screen your child for the program as well as discuss scheduling. If you have any questions, please call (813) 662-1060.