Statement of Privacy and Rights


The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us, whether electronically, on paper, or orally, are kept confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As a patient of Sloane Stecker Physical Therapy, P.C., you have the privacy rights listed below:

· I hereby give my consent to the therapists, staff and associates of Sloane Stecker Physical Therapy, P.C. to provide services to myself and/or family.

· I hereby authorize the staff to release all information necessary to secure payment of benefits. Changes made daily among insurance companies, make it impossible for us to accept the responsibility of knowing if your plan dictates benefits, payment, coverage and whom you can and cannot see. It remains the responsibility of the patients to know his or her own plan.

· I request that payment of authorized insurance benefits be made on my behalf to Sloane Stecker Physical Therapy, P.C. for services rendered to me. I authorize any holder of medical information about me to release to the Division of Medicare and Medicaid Services and it agents any information needed to determine those benefits payable for related services. I understand that my signature requests that payment be made and authorized release of medical information necessary to pay the claim.

· I understand that as part of my healthcare, Sloane Stecker Physical Therapy, P.C. originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care and treatment. I also understand that this information serves as:

o A basis for planning my care and treatment.

o A means of communication among the many healthcare professionals who contribute to my care.

o A means by which a third party payer can verify that services billed were actually provided.

o A tool for routine healthcare operations such as assessing quality of care and reviewing the healthcare professionals.

· By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. Sloane Stecker Physical Therapy, P.C. may condition treatment upon the execution of this consent.