MARIBETH CRUPI PHYSICAL THERAPY LLC
10 ELIZABETH DRIVE
WILMINGTON MA 01887

 

Acknowledgement of Privacy Notices

I acknowledge that I have been informed of the Notice of Privacy Practices and
Patient’s Rights at Maribeth Crupi Physical Therapy LLC, 314 Main Street, Suite 101,
Wilmington, MA 01887, in accordance with the Health Insurance Portability and
Accountability Act of 1996 (“HIPAA”). I am aware that I may ask for a written copy
of this notice to keep for my records should I so desire.

In signing this document I am acknowledging that I am aware of my rights of notice of
privacy while I, or minor child in my care, receive physical therapy treatment or
participate in any other programs at Maribeth Crupi Physical Therapy LLC. This
includes release of protected health information and authorizing payment to made
directly to Maribeth Crupi Physical Therapy LLC by insurers and/or responsible parties,
as explained in the Notice of Privacy Practices effective 2/1/2014.

 

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Patient’s Name (Please Print)

 

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Signature of Patient (Parent/Guardian if Minor) Date