Notice of Privacy Practices

By signing this form, you acknowledge receipt of the Notice of Privacy Practices from Southern Therapy Solutions. The Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to review it carefully. The Notice of Privacy Practices is subject to change. If the Notice is changed, you may obtain a revised copy by contacting our office staff. I hereby consent to and acknowledge receipt of Southern Therapy Solutions Notice of Privacy Practices. I consent that my protected health information be used to provide and coordinate treatment, to obtain payment, and for business operations. I understand that Southern Therapy Solutions Notice of Privacy Practices explains my rights to privacy regarding my protected health information and provides specific information and a complete description of how my health information may be used and disclosed. I acknowledge receipt of the Notice of Privacy Practices from Southern Therapy Solutions.

Signature of Client, Parent, or Guardian
Signature of Witness

Consent to Text
Consent to Text indicates whether the patient has agreed to receive automated text alerts from Southern Therapy Solutions on their mobile phone. Depending on the features the practice offers, text alerts may be about appointments, test results and more. Please select “I Accept” if the patient agrees to receive automated text alerts. Select “I Decline” if the patient declines.

I AcceptI Decline