By signing this consent for medical treatment and billing, I hereby declare the following:
HIPAA Acknowledgement of Receipt of Venture Rehabilitation Group’s Notice of Privacy Practices
By signing this authorization you acknowledge and agree that Venture Rehabilitation Group or its Business Associates may use or disclose the Protected Health Information (PHI) of the above named patient for the purpose of providing treatment, for purposes relating to the payment of services rendered, and for VRG’s general healthcare operations.
By signing below, you are confirming that you have received, reviewed, understand and agree to the Notice of Privacy Practices of VRG regarding the use and disclosure of any of your Protected Health Information created, received or maintained by VRG.