AOB Patient Consent form & Use and Disclosure of PHI

I hereby give my consent for Kinetic O&P to use and disclose

Protected health information (PHI) about me to carry out evaluation, treatment, payment and health care operations

(TPO)( Treatment, Payment and Healthcare Operations) .

(The Notice of Privacy Practices provided by Kinetic O&P describes such uses and disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent.

Kinetic O&P reserves the right to revise its Notice of Privacy Practices

At any time. A revised Notice of Privacy Practices may be obtained by forwarding a

Written request to: Theresa Utt, 1044 X Ray Dr, Gastonia NC 28054

Or @ Phone 704-691-7145

With this consent Kinetic O&P, may call my home or other alternative location and leave a message on voice mail, text, email, or in person in reference to any items that assist the practice in carrying out TPOsuch as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, Kinetic O&P may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”

With this consent, Kinetic O&P may e-mail, mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements and devices. I have the right to request that Kinetic O&P restrict how it uses or discloses my PHI to carry out TPO. HIPAA (Heath Insurance Portability Accountability ACT) allows and disclosures to occur without any need for approval or consent. These disclosuresare made so a covered entity can be paid for services, manage its operations, provide treatment or comply with any government reporting requirements. Practice is not required to agree to my requested restrictions for TPO for carrying out patient care when following the HIPAA guidelines, for treatment, payment and healthcare operations, but if it does, it is bound by this agreement and Kinetic can decline treatment for strict exclusions stated by patient or caregiver..

By signing this form, I am consenting to allow Kinetic O&P to use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Kinetic O&P may decline to provide treatment to me. Authorization to release information: I acknowledge that any information acquired during the course of my treatment may be released, in accordance to the HIPAA Consent Form signed by me, to the insurance company or any other payor involved in reimbursement for claims resulting from services.

I understand and agree that I am responsible for the following expenses: any service my insurance plan deems non-covered-, all coinsurance and or co-payment amounts, all deductibles, any amount that exceeds benefit limits under my insurance plan and any amount my insurance plan deems not covered because I was not insured on the date of service.

I further certify that the information provided by me is true, accurate and complete.

______

Signature of Patient or Legal Guardian

______/____/______

Print Patient’s Name Date

Print Name of Patient or Legal Guardian, if applicable:

1044 X Ray Drive, Gastonia, NC 28054 P: 704-691-7145 F: 704-691-7631