HIPAA RELEASE TO THERAPY WORKS

I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to receive this information is not a health plan or a health care provider, the released information may be redisclosed and may no longer be protected by federal privacy regulations.

Patient name:*

Parent Name/Person authorized to release the information:*

Persons/Organizations authorized to receive the information.

THERAPY WORKS, PC

1509 Atkinson Rd. Suite 1100

Lawrenceville, GA 30043

Specific description of information:

Any Information that will assist with providing therapies referred for by Primary Care Physician.

The patient or the patient’s legal representative must read and initial the following statements:

I understand that this authorization will expire upon notice from Parent/Legal Guardian I(*

Please INITIAL above

I understand that I may revoke this authorization at any time by notifying the providing organization in writing, but if I do, it will not have an effect on any actions taken before the organization received the revocation. *

Please INITIAL above

Send revocations to:

AILEEN DEOGRACIAS, OTR/L

Clinic Director

The purpose of the use or disclosure is: PROVIDE THERAPY SERVICES (Please check where appropriate)*

Occupational TherapySpeech and Language TherapyPhysical Therapy

NOTICE TO PATIENT: The patient or the patient’s legal representative may inspect and/or copy the protected health information to be disclosed in accordance with Therapy Works, PC’s access policies.

Therapy Works, PC does not limit its right to make a use or disclosure of your information that is required by law or permitted to avert a serious threat to the health or safety to the public.

Signature of Patient or Patient's Legal Representative*

Date

Printed name of Patient's Representative/Parent Name:

Relationship to Patient:*

YOU MAY REFUSE TO SIGN THIS AUTHORIZATION

THERAPY WORKS, PC will not condition treatment or payment on the provision of this authorization.

AUTHORIZATION FOR USE AND DISCLOSURE OF INFORMATION