I, the undersigned client (or authorized representative – parent/guardian), hereby voluntarily consent Bridging Bionics Foundation to use or disclose my protected health information as described below.
1. Description of Information to be Used/Disclosed:
This consent applies to the following specific health information:
- My initial evaluation report and plan of care
- Progress notes and session documentation
- Outcome measures and functional status reports
- Diagnostic images or test results (if applicable)
- Photographs or videos of my condition or treatment (if applicable)
2. Purpose of Disclosure:
I understand that my protected health information could be used by or disclosed by
Bridging Bionics’ clinicians and/or staff for purposes of providing physical therapy
and training services, carrying out treatment, reporting and providing information,
and communications with administrators, licensed physical therapists, physical
therapist assistants, doctors, and other allied health professionals.I also understand my
information may be shared as part of case studies or presentations to enhance professional
knowledge and improve client care.
4. Client Privacy Protections:
I understand that while Bridging Bionics Foundation will make every effort to minimize
the use of direct identifiers, the recipients of the information (peers, allied health
professionals) may not be covered by federal privacy regulations (HIPAA).
The organization will instruct all recipients to keep my information confidential.
5. Right to Revoke Consent:
I understand that I have the right to revoke this consent at any time by providing
written notice to Bridging Bionics Foundation. The revocation will be effective upon
receipt but will not apply to information that has already been used or disclosed
in reliance upon this consent.
I understand that I am not required to sign this consent to receive treatment or services.
My treatment will not be conditioned on signing this form.
7. Expiration:
This Consent will expire at the end of the given calendar year upon which it is signed.
8. Signature:
I have read and understand the above information. By signing this form, I voluntarily consent to the use and
disclosure of my protected health information as stated above.
