Release of Information and HIPAA/Privacy Acknowledgment

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Commitment to Your Privacy:
Clinton Lee Physical Therapy, LLC is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time. Dr. Clinton Lee, PT, DPT uses and discloses medical records in accordance with state and federal privacy laws (HIPAA). You may request a copy of the uses and disclosures of this notice of privacy form. 

I understand that Clinton Lee Physical Therapy, LLC is in full compliance with the Health Insurance Portability and Accountability Act. By signing below, I acknowledge I have access to Clinton Lee Physical Therapy, LLC's  notice of the privacy practices for PHI.. I give permission to Dr. Lee to release medical information or other information necessary for treatment, billing and for purposes of insurance processing.

 

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Signature of Patient or Legal Guardian                                    Date

 

__________________________________________           ____________
Printed Name                                                                               Date

 


Notice of Informed Consent

I hereby consent to evaluation and/or treatment of my condition by physical therapist Dr. Clinton Lee, PT, DPT. The physical therapist has fully explained to me the nature and purposes of the procedures, evaluation and course of treatment, and has witness my signature of this consent in his or her presence. The physical therapist has informed me of expected benefits and possible complications or discomfort, which may result from skilled physical therapy care. In addition, the physical therapist has explained to me the risks of receiving no treatment. The physical therapist has explained that there is not 100% guarantee that the proposed course of treatment will improve my condition. I have the opportunity to ask any and all questions before receiving treatment and all my questions have been answered to my satisfaction. I confirm that I have read and fully understand this consent form. 

 

__________________________________________          ____________
Signature of Patient or Legal Guardian                                    Date

 

__________________________________________           ____________
Printed Name                                                                               Date