Pediatric Skill Builders
Occupational and Physical Therapy Services in Orlando, Florida
HIPAA Patient Consent Form
Patient Consent for Use and Disclosure of Protected Health Information
With my consent, Pediatric Skill Builders may use and disclose protected health information about me to carry out treatment, payment, and healthcare operations. Please refer to Pediatric Skill Builders for a more complete description of such uses and disclosures.
I have the right to review the notice of privacy practices prior to signing this consent.
Pediatric Skill Builders reserves the right to revise its notice of privacy practices at any time. A revised notice of privacy practices may be obtained by forwarding a written request to Pediatric Skill Builders 331 North Maitland Ave, Suite A-3, Maitland, FL 32751.
With my consent, Pediatric Skill Builders may call my home or other designated location and leave a message on my voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any call pertaining to my child’s therapy care.
With my consent, Pediatric Skill Builders may e-mail to my home or other designated location any items that assist the practice in caringout TPO, such as appointment reminders, patient statements and information regarding my child’s therapy care. I have the right to request that Pediatric Skill Builders restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my request restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to Pediatric Skill Builders use and disclosure of my PHI to carry out TPO. I may revoke my consent inwriting except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Pediatric Skill Builders may decline to provide treatment to me.
Please fill out each field if possible and click "Submit". If you have any difficulty, please contact us at (407) 389-4357.