I have read and fully understand Razo Restoration Therapy Notice of Information Practices. I understand that Razo Restoration Therapy may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payments, understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operation if I notify the practice. I also understand that Razo Restoration Therapy will consider requests for restriction on a case by case basis, but does not have to agree to requests for restrictions.

 

Consent for Treatment. I, the undersigned, give Razo Restoration Therapy my permission to evaluate and treat my injury. I further understand that in the course of recommended treatment, condition may worsen on rare occasions. I further understand that no guarantee or promise has been made to me concerning the results of treatment.

 

Authorization to Release Information. I authorize this office to release any information pertinent to my case to any insurance company or attorney to facilitate collections on my balance at this office.

 

PRIVACY NOTICE ACKNOWLEDGEMENT We are very concerned with protecting your privacy, especially in matters that concern your personal health information. In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to supply you with a copy of our privacy policies and procedures. We encourage you to read this document carefully, for it outlines the use and limitations of the disclosure of your health information and your rights as a patient. If you ever have any questions or concerns regarding the use or dissemination of your personal health information, we would be happy to address them.