Our goal is to respectfully provide you with highest quality orthotic or prosthetic care to help you maintain an active and healthy lifestyle. We continually strive to improve our processes in order to ensure you are receiving the best possible care and that you and your referring physician and/or physical therapist are actively involved in the process. Please take a moment to read the HIPAA information below before proceeding with entering your information in our online Patient Intake Form. If you have any questions at any time, please call our office at (806) 792-0395 for further assistance.
By signing below, you consent to the use and disclosure of your protected health information by The BracePlace, our staff, and our business associates for treatment, payment and health care operations purposes. For a more detailed description of our uses and disclosures of protected health information, please review our HIPAA Notice of Privacy Practices ("Notice"), which you acknowledge receiving on this date. You have the right to review our Notice prior to signing this consent.
The terms of this Notice may change. If the terms do change, you may obtain a revised Notice by simply contacting us at (806) 792-0395 and requesting a revised Notice. You have the right to request that we restrict our uses or disclosures of your protected health information that we are otherwise permitted to make for treatment, payment and health care operations, although we are not required to agree to these restrictions. However, if we agree to further restrictions, they are binding on us. Finally, you have the right to revoke the consent in writing, except to the extent that we have taken action in reliance on it.
I have read, understand and acknowledged the above information regarding my consent for the use and disclosure of protected health information.
Please sign by entering your name and date of birth below.
Your Date of Birth: //