Notice Of Privacy Practices Acknowledgement​ form

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that the information can and will be used to:

• Conduct, plan and direct my treatment and follow-up amoung the
  multiple healthcare providers who may be involved in that treatment directly and indirectly
• Obtain payment for third-party payers
• Conduct normal healthcare operations, such as quality assessment and physician's certifications

I have reviewed/read the office's Notice of Privacy Practices posted in the lobby. I understand your Notice of Privacy Practices contains a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practice from time to time and that I may contact this organization at any time to obtain a current copy of its Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operation. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

CANCELLATION / NO SHOW / LATE FEE

We understand that you may sometimes need to reschedule appointments. When we make your appointment, please understand we are reserving time for you to see a therapist. This courtesy makes it possible to give the best services here at Revolve PT. If you need to reschedule an appointment, please call the clinic as soon as possible or call at least 24 hours in advance.

• If canceling the same day as your session or simply no-show, you will be responsible for a $50 out-of-pocket cancellation fee.
• If arriving more than 15 minutes late a $30 fee will be applied to your visit.

We thank you for your trust in us here at Revolve Physical Therapy.

DISCLOSURE OF MEDICAL RECORDS

I authorize the following individuals to have access to my medical and billing records: