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Rehab & Return to Sport
Rehab & Return to Sport Overview
Physical Therapy
Pelvic Floor Therapy
ACL Return to Sport
TPI Movement Screen
ARPwave
Athletic Performance
Overview & Programs
Schedule Inquiries
Online Training
Resources
HIPAA Privacy Authorization Form
Physical Therapy Intake Form
Patient Information Consent Form
Patient Referral and Benefit Policy
About
About AE
AE Staff
Locations
Contact Info
Internships
Let’s Talk
Rehab & Return to Sport
Physical Therapy
Pelvic Floor Therapy
ACL Return to Sport
TPI Movement Screen
ARPwave
Athletic Performance
Overview & Programs
Schedule Inquiries
Resources
Online Training
HIPAA Privacy Authorization Form
Physical Therapy Intake Form
Patient Information Consent Form
Patient Referral and Benefit Policy
About
AE Staff
Locations
Contact Info
Internships
Rehab & Return to Sport
Rehab & Return to Sport Overview
Physical Therapy
Pelvic Floor Therapy
ACL Return to Sport
TPI Movement Screen
ARPwave
Athletic Performance
Overview & Programs
Schedule Inquiries
Online Training
Resources
HIPAA Privacy Authorization Form
Physical Therapy Intake Form
Patient Information Consent Form
Patient Referral and Benefit Policy
About
About AE
AE Staff
Locations
Contact Info
Internships
Let’s Talk
HIPAA Privacy Authorization Form
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Name
*
First
Last
Phone
*
Email
*
This authorization for release of PHI covers the period of healthcare (check one)
*
All past, present, and future periods
Date Range (define below)
From / To Date
I hereby authorize the release of PHI as follows (check one)
*
I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).
I authorize the release of my complete health record with the exception of the following information: Mental health records, Communicable diseases (including HIV and AIDS), Alcohol/drug abuse treatment, Other (specify below)
Other - PHI
authorization Phone Email
Printed name of patient
*
First
Last
Representation
I am a personal representative of this member
Representative's Name
Relationship to member
Next: Signature
×
×
×
×
×