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Patient Authorizations

CONSENT FOR EVALUATION AND TREATMENT

I hereby authorize Optimum Health and Wellness Physical Therapy, Inc. (hereafter referred to as OHWPT, Inc.) and/or its affiliates, employees, or agents to perform physical examination and/or medical treatment as directed by my referring provider. This includes, but is not limited to, required medical examinations, therapeutic procedures, evaluations, and ongoing treatment to be carried out by the designated staff. (Please initial )

RELEASE OF INFORMATION

I hereby authorize OHWPT, Inc. and/or its affiliates to disclose to my employer (only under Workmen's Compensation), prospective employer, insurance company, and/or third-party payer any pertinent medical information, test results and findings made during the course of this examination and/or treatments. I also authorize OHWPT, Inc. and/or its affiliates to release any medical information, test results, and any appropriate information concerning my medical history, examinations, treatments, or other diagnostic procedures, including copies of my records to official requesters, including but not limited to insurance companies, third party administrators, utilization review organizations, health care service plans, or to any other person or entity as necessary in connection with certification, payment, or reimbursement for services rendered. I further acknowledge that release of such information is pursuant to the following paragraph. (Please initial )

CONFIDENTIALITY

It is the policy fo OHWPT, Inc., and its affiliates, to protect all medical records against loss, tampering, destruction, and access by unauthorized persons. I understand that medical records may be periodically reviewed by national accreditation or certification surveyors and other necessary quality assurance personnel, and I authorize such release of information. I further acknowledge that my records and associated documentation may be disclosed to third parties including government agencies, as required by Law, including but not limited or pursuant to warrant, subpoena, or court order, and I hereby agree not to pursue any action against OHWPT, Inc. and/or its affiliates for any damages I may suffer as a result of such disclosure. (Please initial )

CONSENT FOR TREATMENT OF A MINOR

Is the patient a minor? If yes, Parent/Guardian initial below. Yes No

As a parent and/or legal guardian, I authorize OHWPT, Inc. to treat the minor patient named in the attached forms while I am not present. (Please initial )

By signing this authorization form I acknowledge that I have fully read or had this form read/or explained to me, and that I fully understand its contents. I have been given ample opportunity to ask questions, and any questions have been answered satisfactorily.

Would you like to be added to our mailing list? Yes No

Parent/Legal Guardian or Representative (If applicable) Date

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Timestamp

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January 27, 2020 2:05 pm AKDT

Patient Authorizations Uploaded by Michelle Fisher - office@ohwpt.com IP 206.223.200.174

June 8, 2020 3:32 pm AKDT

Nikki Brown - nikki@ohwpt.com added by Christopher Comstock - emily@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

July 1, 2021 4:30 pm AKDT

Stephanie Cain - stephanie@ohwpt.com added by Optimum Health and Wellness - nikki@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

July 9, 2021 5:05 pm AKDT

Elizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - nikki@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

February 4, 2022 12:35 pm AKDT

Elizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - jaimee@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

March 15, 2022 11:00 am AKDT

Elizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

March 15, 2022 11:00 am AKDT

Jaimee Watson - jaimee@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

March 30, 2022 8:28 am AKDT

Elizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

March 30, 2022 8:28 am AKDT

Jaimee Watson - jaimee@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

May 31, 2022 3:30 pm AKDT

Annie Morris - annie@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

May 31, 2022 3:31 pm AKDT

Document owner elizabeth@ohwpt.com has handed over this document to jaimee@ohwpt.com 2022-05-31 15:31:48 - 206.223.197.206

May 31, 2022 3:31 pm AKDT