Patient Information Consent Form


I understand that Clinton Lee Physical Therapy, LLC/PhysioStrength (the Company) may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the company. I also understand that the Company will consider requests for restrictions on a case by case basis, but does not have to agree to requests for restrictions. I hereby consent to the use and disclosure of my personal health information for purposes as noted in the Company’s Notice of Patient Privacy Practices. In doing so, I hereby release from any and all legal liability that may arise from the release of such information. I agree that a copy of this authorization may be used in place of the original.I understand that I retain the right to revoke this consent by notifying the Company in writing at any time except for that action which has already been taken. It shall be effective only long enough to answer the purpose of which it is given and no further confidential information will be released without the execution of an additional written authorization. I was provided access to, have read and understand the Notice of Patient Privacy Practices.

 
Name *
Name
Date
Date