HIPPA CONSENT

DeBruin Physical Therapy, LLC

HIPPA Consent

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I understand that by signing this consent, I authorize DeBruin Physical Therapy, LLC, its employees, and agents to use and disclose my protected health information to carry out:

• Treatment, including direct or indirect treatment by other healthcare providers involved in my care
• Obtaining payment from third party payers (insurance companies)
• The day-to-day administration of this practice

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and business operation. I also understand that DeBruin Physical Therapy, LLC is not required to agree to any such restrictions, but that if it does agree, it will be bound to comply with any and all restrictions to which it agrees.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date of revocation will not be affected.