Your initials consent to the following: Fields marked with an asterisk (*) are required.
I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand this information can and will be used to:
Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
Obtain payment from third-party payers directly to Optimum Therapies of North Dakota, Inc.
Conduct normal healthcare operations such as quality assessments and physician certifications.
*As a courtesy to our staff and other patients we ask that you provide a 24-hour notice if you are unable to keep your scheduled appointment.
*After three (3) cancel/no-show occurrences, we reserve the right to review each case and determine discharge as appropriate.