Notice of privacy practices

I consent to the use or disclosure of my protected health information (PHI) by Ozark Rehab and Therapy for the purpose of diagnosing or providing treatment to me, obtaining payment of my health care bills or to conduct the health care operations of Ozark Rehab and Therapy.  I understand that diagnosis or treatment of me by the practice of Ozark Rehab and Therapy may be conditioned upon my consent as evidenced by my signature on this document.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice.  Ozark Rehab and Therapy is not required to agree to the restrictions that I may request. However, if Ozark Rehab and Therapy agrees to a restriction that I request, the restriction is binding on the staff of Ozark Rehab and Therapy.

I understand that I have a right to review Ozark Physical Therapy’s Notice of Privacy Practices prior to signing this document.  The Notice of Privacy Practices provides information about how Ozark Rehab and therapy may use and disclose protected health information about me.  A copy of the Notice of Privacy Practices is also provided in the waiting area of Ozark Rehab and Therapy.

Ozark Rehab and Therapy reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.  I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy to be sent in the mail or asking for one at the time of my next appointment.

I hereby authorize Ozark Rehab and Therapy to release my health care information to the person listed below, with proof of identity, if I am unable to do so myself.  I also understand that my medical records may be transmitted electronically to the requested third party.

Patient Name *
Patient Name
Date of Birth
Date of Birth
Date of signature *
Date of signature
Address of Listed Person
Address of Listed Person
Phone of Listed Person
Phone of Listed Person
Date of Signature *
Date of Signature