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HIPAA Compliance Client Consent Form for New Wave Therapy
 

Our Privacy Policy provides information about how we may use or disclose protected health information (PHI).

The notice contains a client’s rights section that describes your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.
 

The terms of the notice may change. In that case, you will be notified at your next visit to update your signature/date.
 

You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall owner this agreement. The HIPPA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous use in a publication. You have the right to revoke this consent in writing, signed by you such as a revocation will not be retroactive.
 

By signing this form, I understand that:
 

  1. My protected health information can be disclosed or used for the purpose of treatment, payment, or healthcare operations.

  2. New Wave Therapy has the right to restrict the use of PHI but New Wave Therapy does not have the right to agree to those restrictions.

  3. New Wave Therapy has the right to restrict the use of PHI but New Wave Therapy does not have to agree to those restrictions.

  4. The client has the right to revoke this consent in writing at any time and all full disclosures will then cease.

  5. New Wave Therapy may condition the receipt of treatment upon execution of this consent.


May we phone, email, or send a text to you to confirm appointments?   YES    NO


May we leave a message on your answering machine at home or on your cell phone?

  Yes     NO


May we discuss your health condition with any other members of your family?

  YES    NO


If YES, please name the members that are allowed:

_____________________________________________________

_____________________________________________________

_____________________________________________________

 

This consent signed by: ______________________________________________

(Print Name Please)

 

Signature: __________________________________________ Date: _____________________

Witness: ___________________________________________ Date: _____________________

Date June 20th, 2024

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