Orthopaedic Physical Therapy and Associates, Inc
DBA: Premier Physical Therapy Services

Our notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights Section describing your rights under the law. You have the right to review our Notice before signing this consent. The terms of our notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

Under the Health Insurance Portability & Accountability Act of 1996, as amended and supplemented (HIPPA), you have certain rights to privacy regarding your protected health information. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or healthcare operations. We are not required to agree to your request for a restriction. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and healthcare operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. Premier Physical Therapy Services provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).