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Acknowledgement
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Acknowledgement & Assumption of Risk
I understand that I am being asked to carefully read each of the provisions in this form. I acknowledge and agree to have receive therapy services from Branched Out Therapy, Inc. and/or any employee or independent contractor employed by Branched Out Therapy, Inc.
I acknowledge that there is some inherent risks associated with the use of therapy equipment that cannot be eliminated regardless of the care taken to avoid injuries.
I understand the risks and I hereby assert that my participation is voluntary and that I knowingly assume such risks without holding Branched Out Therapy, Inc. and/or any employee or independent contractor employed by Branched Out Therapy, Inc. accountable for any losses, injuries or other damages occurring to the client and/or myself. I further understand that I am fully responsible for my own safety.
Acknowledgement That You Have Received Our HIPAA Privacy Notice
Branched Out Therapy, Inc., is required by law to keep your health information and records safe.
This information may include:
Notes from your doctor, teacher or other healthcare provider
Medical history
Test results
Treatment notes
Insurance information
We are required by law to give you a copy of our privacy notice. This notice tells you how your health information maybe used and shared.
I acknowledge that I have received a copy of Branched Out Therapy, Inc. HIPAA Notice of Privacy Practices that fully explains the uses and disclosures they will make with respect to my individually identifiable health information.
I have had the opportunity to read the notice and to have any questions regarding the notice answered to my satisfaction.
I understand Branched Out Therapy, Inc. cannot disclose my health information other than as specified in the notice.
I understand that Branched Out Therapy, Inc. reserves the right to change the notice and the practices detailed therein if it sends a copy of the revised notice to the address I have provided.
General Acknowledgement of Forms
I hereby acknowledge and agree that I had read all of the forms and documents provided to me in connection with evaluation and treatment provided by Branched Out Therapy, Inc. and/or their employees.
I understand the meaning and intent of the provided forms and agree to all content included.
I have been given an opportunity to ask questions about the provided forms and Branched Out Therapy, Inc. has answered all questions I’ve asked to my satisfaction.
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