Our notice of Privacy Practice provides information about how we may use and disclose protected health information about you. The Notice contains a Patient’s Rights section describing your rights under the law.

You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting or Privacy Officer @ 310-850-5373. You have the right to request that we restrict how we protect health information about you, is used or disclosed for treatment payment and health care operations. You have the right to revoke this Consent, in a written statement, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. Ocean P.T. & Wellness provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understands that:
Protected health information may be disclosed or used for treatment, payment, or health care operations.

Ocean P.T. & Wellness has a Notice of Privacy Practice and the patient has the opportunity to review this Notice.

Ocean P.T. & Wellness reserves the right to change the Notice of Privacy Practices.

The patient has the right to restrict the uses of their information, but Ocean P.T. & Wellness does not have to agree to those restrictions.

The patient may revoke this Consent in writing at any time and all future disclosures with then cease.

Ocean P.T. & Wellness may condition receipt of treatment upon the execution of this consent.

Please sign by ELECTRONIC SIGNATURE

FIRST NAME: