Patient Forms

State and federal laws, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the HIPAA Omnibus Final Rule of 2013 require that we, Core Revitalizing Center (hereby referred to as CRC), keep your medical records private. Such laws require that CRC provide you with this notice informing you of our privacy of information policies, your rights, and our duties.

PRIVACY OF INFORMATION POLICIES

You have the right, as a client or legal guardian of the client, to be informed about your (or your guardee’s) condition and the recommended medical or diagnostic procedure to be used so that the client may make the decision whether or not to approve any suggested treatment or procedure after knowing the risks and hazards involved.

CONSENT TO TREATMENT

Core Revitalizing Center is committed to providing quality health care.  It is our pledge to provide this care with respect and dignity. In keeping with this pledge and commitment, we present the following Patient Rights and Responsibilities.

PATIENT RIGHTS AND RESPONSIBILITIES

If you want Core Revitalizing Center to share your confidential information, you can use this form to choose what is shared, how it's shared, with whom, and for how long.

RELEASE OF INFORMATION

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Revitalizing the Mind-Body Connection

(941) 500-9292 - phone/fax

core@corerevcenter.com

7357 International Place Ste. 107, Lakewood Ranch, FL 34240

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