Pediatric Skill Builders

Occupational and Physical Therapy Services in Orlando, Florida

Child holding paint brushes

HIPAA Patient Consent Form

Patient Consent for Use and Disclosure of Protected Health Information

Please list the people/doctors/therapist that you authorized to have access to your child's information:

Contact #1:

Contact Name
Phone Number
Relationship to Patient

Contact #2:

Contact Name
Phone Number
Relationship to Patient

Do we have permission to:

Send a message via Fax?

Leave a message on your answering machine at home?

Leave a message at your place of employment?

Discuss your condition with any family member?

Discuss your condition with any member of your household?


If yes, Whom?
Relationship:
Name of Legal Guardian:
Patient's Name:
Today's Date

Instructions

Please fill out each field if possible and click "Submit". If you have any difficulty, please contact us at (407) 389-4357.