901 Englewood Parkway Ph: 303-761-3085
Suite 108 Fax: 303-761-4066
Englewood, CO 80110 foothillspt@yahoo.com
Patient Consent for Use and Disclosure of
Protected Health Information
I hereby give my consent for Foothills Physical Therapy to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by Foothills PT describes such uses and disclosures more completely.)
I have the right to review the Notice of Privacy Practices prior to signing this consent. Foothills PT 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 Bronny Brooks at Foothills Physical Therapy, 901 Englewood Parkway Suite 108, Englewood, CO 80110.
With this consent, Foothills PT may call my home or other alternative location and leave a message on 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 calls pertaining to my clinical care, including laboratory test results, among others.
With this consent, Foothills PT may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked 'Personal and Confidential.'
With this consent, Foothills PT may e-mail to my home or alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Foothills PT restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound to this agreement.
By signing this form, I am consenting to allow Foothills PT to use and disclose my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent or later revoke it, Foothills PT may decline to provide treatment to me.
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Signature of Patient or Legal Guardian
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Print Patient's Name Date
