HIPAA authorization form

I, Patient/ Parent/ Guardian, hereby authorize the use or disclosure of my protected healthinformation as described below:

1. AUTHORIZED PERSONS TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION Courtney Mattingly/ Granite State Myofunctional Therapy LLC is authorized to disclose the following protected health information to my Myofunctional Therapist at Granite State Myofunctional Therapy LLC of Nashua, New Hampshire 03063. 2. DESCRIPTION OF INFORMATION TO BE DISCLOSEDThe health information that may be disclosed is:Medical recordsPhotos/ VideosAll past, present, and future periods of health care information may be shared.3. PURPOSE OF THE USE OR DISCLOSUREThe purpose of this use or disclosure is Photos/ Videos for educational and marketing purposes.4. VALIDITY OF AUTHORIZATION FORMThis Authorization Form is valid beginning on the start of my treatment and expires when business closes or isno longer in operation.5. ACKNOWLEDGMENTI understand that the information used or disclosed under this Authorization Form may be subject to redisclosure by the person(s) or facility receiving it and would then no longer be protected by federal privacy regulations.I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned onwhether I sign this authorization.I have the right to refuse to sign this Authorization Form. If signed, I have the right to revoke thisauthorization, in writing, at any time. I understand that any action already taken in reliance on thisauthorization cannot be reversed, and my revocation will not affect those actions.

Patient Name

Parent/ Guardian

I accept and am aware of HIPAA policies

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Treatment Agreement for patients over 18

I am willingly accepting to start treatment with Granite State Myofunctional Therapy LLC. I am aware that therapy results are soley based on my compliance and practice of therapy. I am aware that I will be paying up front and that my insurance may or may not reimburse me and I do not hold Granite State Myofunctional Therapy LLC responsible.

Full Name

Date of Birth

I accept the treatment agreement

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Treatment Agreement for 17 and under

I am willingly accepting to start treatment with Granite State Myofunctional Therapy LLC. I am aware that therapy results are soley based on my child's compliance and practice of therapy. I am aware that I may have to take part in the therapy and watch over my child to ensure they are compliant. I am aware that I will be paying up front and that my insurance may or may not reimburse me and I do not hold Granite State Myofunctional Therapy LLC responsible.

Responsible Party's Name

Child's Name

Patient's Date of Birth

I accept the terms of the agreement

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