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Patient Forms & Privacy Practices

North Boulder Physical Therapy Sports Rehabilitation

The forms available through this page can be downloaded and printed, giving you the ability to fill out the necessary paperwork before you visit our office.

New Patient Forms

PLEASE DOWNLOAD, PRINT, COMPLETE THE FORMS BELOW AND BRING THEM TO YOUR APPOINTMENT

  1. Notice of Patient Privacy Act (HIPAA)
  2. Intake Form-all patients
  3. Motor Vehicle Accident-only car accident patients

Other Forms

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Practice Privacy Policies Summary

Effective Date: April 14, 2003

Updated: January 30, 2014

If you have any questions about this notice, please contact Debra J. Layne, Managing member NBPT or the office manager at (303) 413-9903.

OUR PLEDGE REGARDING HEALTH INFORMATION:

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this health care practice, whether made by your personal doctor or others working in this office. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

We are required by law to:

  • Make sure that health information that identifies you is kept private.
  • Give you this notice of our legal duties and privacy practices with respect to health information about you; and:
  • Follow the terms of the notice that is currently in effect.

The summary of our notice of privacy act is available by download on this page. Please carefully read and review this notice prior to arriving for your first visit. Thank you!

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