Felice Center

Speech, Language, Occupational and Physical Therapy

Consent for Purposes of
Treatment, Payment and
Healthcare Operations

Felice Center for Pediatric Rehabilitation
7205 Aloma Ave, Winter Park, FL 32792
Tel: (321) 972-3960     Fax: (321) 972-3960     Email: office@felicecenter.com

Please complete the intake form in order for the office to process and contact you to schedule an appointment.

With my consent, Felice Center may use or disclose protected health information (PHI) about for the purpose of diagnosing or providing treatment, obtaining payment for my health care bills, or conduct health care operations (TPO) of Felice Center. I understand that diagnosis and treatment of may be conditioned upon my consent as evidenced by my signature on this document. Please refer to Felice Center Notice of Privacy Practices for a complete description of such uses and disclosures.

I have a right to review the Notice of Privacy Practice prior to signing this consent.

Felice Center reserves the right to revise its Notice of Privacy Practices at any time. I may obtain a revised notice of privacy practices by calling the office and requesting a copy be sent in the mail or asking for one at the time of my next appointment.

With my consent, Felice Center, may call my home or other designated location and leave message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders and patient statements. I have the right to request that Felice Center restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Felice Center, the use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Felice Center may decline to provide treatment to .

Name of Patient or Personal Representative *
Date *
Description of Personal Representative’s Authority/Relationship to Patient

Do we have your permission to:

Send a message via fax? Yes No
Leave a message on your answering machine at home? Yes No
Leave a message at your place of employment? Yes No
Discuss your condition with any member? Yes No
Discuss your condition with any member of your household? Yes No
If Yes, whom?