Privacy Policy/HIPAA Privacy Authorization Form
At drivePT, we abide by all healthcare regulations governing standard practice
regarding your personal and health related information. Protected Health information
includes any identifiable information related to you and your care, required by the Health
Insurance Portability and Accountability Act (HIPPA), 45 C.F.R. Parts 160 and 164).By
law, drivePT is permitted to discuss relevant case information with other healthcare or
legal professionals who are currently a part of your care, just as they are permitted to
provide us pertinent details to help provide the highest quality of care possible. We will
not release your protected health information or discuss your case without expressed
written permission. If there is anyone you wish to be allowed to discuss your care,
please note names below. Please note that you are free to change your mind at any
time in writing. (Examples: family members, coaches, doctors, insurance company,
etc…)

You have the right to request any/all of your medical records from drivePT. We will
supply you with your records. A small administrative fee may apply based on the type
and volume of request.
Email address *
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed
and how you can get access to this information. Please review it carefully.
Permitted Uses and Disclosures
drivePT my disclose your medical record for:
1. Coordination of treatment with other health care providers, or in emergency situations
with serious threats to health or safety.
2. Payment of services rendered (3rd party, Auto, or Worker’s compensation)
3. Healthcare operations: We may use your healthcare records to check the quality of
healthcare you receive and in audits, fraud, and abuse
programs/planning/management.
4. For legal purposes as compelled according to local, state, and federal regulations.
5. Family or friends involved in your direct care permitted by you.
6. For Public Health Authorities to control or prevent disease, injury, disability, deaths,
abuse, or neglect.
7. We may use and disclose your PHI for research purposes, but we will only disclose
PHI if approved by an authorized institutional review board or a privacy board that has
reviewed the research proposal and has set up protocols to ensure the privacy of your
PHI.
Patient Rights
1. Request restrictions on the use of your medical information for any of the services
listed above, however drivePT is not required by law to accept your request.
2. Request confidential communication of your protected health information.
3. Request copies of your medical information to be delivered to other locations. You
may be responsible for any expenses incurred for these alternative services (i.e.
copying and mailing records)
4. Request to view your medical records.
5. Request an addition or amendment be made to your medical information, subject to
certain restrictions.
6. Request a paper copy of the Notice of Privacy Practices.
Changes to Privacy Practices
We have the right to make revisions to this notice and to our privacy practices at any
time. Revisions will apply to all PHI that we currently have, and any PHI that we obtain
or generate in the future. Revisions will be posted with this notice in our clinic and on
our website.
Please name anyone you wish to be allowed to discuss your care, if any.
Your answer
First Name *
Your answer
Last Name *
Your answer
Today's Date *
MM
/
DD
/
YYYY
I acknowledge that I have received a copy of drivePT’s Notices of Privacy Practices. This notice provides information about how we may use and disclose the medical information that we maintain about you. It also explains how you can access this information. By signing, you acknowledge that you have reviewed this notice and understand your rights. *
Required
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of drivePT LLC. Report Abuse