HIPPA Acknowledgement
Holistic Family Occupational Therapy, LLC
Client Name
In accordance with the privacy regulations promulgated under the Health Insurance Portability and Accountability Act, 45 (forty-five) CFR parts 160 and 164 (the “Privacy Regulations”), Holistic Family Occupational Therapy, L.L.C., and Jennifer Perigord, OTR/L understand and agree to abide by the Facility privacy policies and to not use or further disclose a patient’s personal health information except as expressly permitted by the Agreement or as otherwise authorized in writing by the patient through a consent or authorization meeting the requirements of the Privacy Regulations. Holistic Family Occupational Therapy, L.L.C. and Jennifer Perigord, OTR/L may only use a patient’s personal health information for the sole purpose of treatment, and/or health care operations and may not release any information to unauthorized parties. Holistic Family Occupational Therapy, L.L.C. and Jennifer Perigord, OTR/L agree to implement appropriate safeguards to prevent the unauthorized use and disclosure of any patient’s personal health information received by Facility under this Agreement. In addition Holistic Family Occupational Therapy, L.L.C. and Jennifer Perigord, OTR/L shall make available to the Facility the protected health information for amendment purposes, should changes to the information be necessary or to provide an accounting of disclosures of the protection health information. If any unauthorized disclosure of personal health information occurs, Holistic Family Occupational Therapy, L.L.C., and Jennifer Perigord, OTR/L shall immediately contact Facility to inform them of the disclosure and any remedial action taken to prevent further disclosures Holistic Family Occupational Therapy, L.L.C., and Jennifer Perigord, OTR/L understand that any unauthorized disclosure of a patient’s personal health information is grounds for immediate termination of the Agreement and/or a staffing assignment.
Parent/Guardian or Adult Name
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First Name
Middle Name
Last Name
Date
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Month
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Day
Year
Date
I agree:
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to abide by all facility policies in regards to HIPPA.
Signature
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Submit
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