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Moving And Grooving Pt

Pediatric Physical Therapy Services
Does My Child Need PT?
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Pediatric Physical Therapy Services
Does My Child Need PT?
Resources
- Forms
- Blog
- FAQ
- Testimonials
About
Contact
Book Online

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Hipaa Authorized Form

, hereby authorize the use or disclosure of my protected health information as described below:

1. AUTHORIZED PERSONS TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

is authorized to disclose the following protected health information to my Physical Therapist, Dr. Nikki Robinett, PT, DPT at Moving & Grooving Pediatric Physical Therapy of Scottsdale,

2. DESCRIPTION OF INFORMATION TO BE DISCLOSED

The health information that may be disclosed is:
Medical records Communicable diseases (including HIV and AIDS) Alcohol/drug abuse treatment Mental health records All treatment records Other: Birth Records

All past, present, and future periods of health care information may be shared.

3. PURPOSE OF THE USE OR DISCLOSURE

The purpose of this use or disclosure is so that my child's physical therapist has all pertinent information..

4. VALIDITY OF AUTHORIZATION FORM

This Authorization Form is valid beginning on

and expires When the child is discharged from physical therapy.

5 ACKNOWLEDGMENT

I understand that the information used or disclosed under this Authorization Form may be subject to re- disclosure by the person(s) or facility receiving it and would then no longer be protected by federal privacy regulations.

I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization.

I have the right to refuse to sign this Authorization Form. If signed, I have the right to revoke this authorization, in writing, at any time. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

Signed of behalf of

, patient's

By:

Date:

Name

Photo Release

PHOTO RELEASE For good and valuable consideration, the receipt of which is hereby acknowledged, I,

hereby grant Moving and Grooving Pediatric Physical Therapy permission to use my likeness in a photograph in any and all of its publications, including but not limited to all of Moving and Grooving Pediatric Physical Therapy's printed and digital publications. I understand and agree that any photograph using my likeness will become property of Moving and Grooving Pediatric Physical Therapy and will not be returned.

I acknowledge that since my participation with Moving and Grooving Pediatric Physical Therapy is voluntary, I will receive no financial compensation.

I hereby irrevocably authorize Moving and Grooving Pediatric Physical Therapy to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing Moving and Grooving Pediatric Physical Therapy's programs or for any other related, lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph.

I hereby hold harmless and release and forever discharge Moving and Grooving Pediatric Physical Therapy from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

Printed Name

Date:

Signature: