By signing or submitting this form, I acknowledge and agree that:
- I have been informed of my rights under the Health Insurance Portability and Accountability Act (HIPAA).
- I understand that Doctor’s Physical Therapy & Sports Institute (DPTSI) may use and disclose my health information for purposes of treatment, payment, and healthcare operations.
- My information will be kept private and secure in accordance with HIPAA regulations.
- I have the right to request restrictions, access my records, and receive a copy of the Notice of Privacy Practices.
- I consent to the use of my information as described, and understand I may revoke this consent in writing at any time, except to the extent that action has already been taken in reliance on it.
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Last Updated: December 16, 2025