Mvp Patient Information (Page 3 of 7) in pdf

Mvp Patient Information Page 3

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

AND AUTHORIZATION OF RELEASE OF SPECIFIC INFORMATION

Patient Name:_____________________________________________ Clinic:___________________________________

MVP Physical Therapy reserves the right to modify the privacy practices outlined in this notice.

I acknowledge that I have received or have had the opportunity to receive a copy of the official Notice of

Privacy Practices from MVP Physical Therapy, Inc.

Signature:_________________________________________________

Date:____________________________

(PARENT OR GUARDIAN MUST SIGN FOR PATIENTS UNDER 18 YEARS OF AGE)

Relationship to Patient: ☐ Self

☐ Mother

☐ Father

☐ Legal Guardian

Initial all statements that apply:

I authorize you to leave messages regarding my appointments on my answering machine or

voicemail as listed on my patient information.

___________

I authorize you to discuss my appointments with my spouse as listed on my patient information.

In addition to my referring doctor, I authorize you to communicate with and send reports &

___________

evaluations to the following:

_________________________________________________________________________________

By signing this authorization, I understand that this does not authorize release of medical information by MVP

Physical Therapy, Inc. to any other organization or agency unless I grant further authorization. I also

understand that these authorizations may be revoked at anytime.