This form provides consent for the provision of speech therapy services for your child in a group setting and outlines how their protected health information (PHI) will be used, stored, and shared in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

By signing below, you consent to the participation of your child in group speech therapy sessions. These sessions may involve other patients in a group setting, and during these sessions, your child’s progress, goals, and therapy plans may be discussed.

We are committed to protecting your child’s privacy and ensuring that their health information is kept confidential. In accordance with HIPAA, your child’s personal health information will only be shared with those involved in their care or as required by law.

• What We Share:
o Your child’s speech therapy progress and treatment plan may be shared with healthcare providers involved in their care.
o Information may also be shared with your insurance company to process claims if applicable.

• When We Share:
o We may disclose your child’s information only when necessary, such as with other healthcare providers, treatment team members, or when required by law (e.g., to report child abuse).

• How We Protect Information:
o All information is stored securely, and we utilize secure methods of communication such as encrypted emails and password-protected systems for storing data.

You have the following rights regarding your child’s health information:

1. Right to Access: You have the right to request access to your child’s medical records.

2. Right to Amend: You have the right to request an amendment to your child’s medical records if you believe the information is incorrect or incomplete.

3. Right to Restrict Use: You have the right to request restrictions on how your child’s information is used or disclosed, though we are not required to comply with all requests.

4. Right to File a Complaint: If you believe your privacy rights have been violated, you have the right to file a complaint with our practice or the U.S. Department of Health & Human Services.

I, the undersigned, consent to my child’s participation in group speech therapy sessions as described above. I understand that while reasonable efforts will be made to maintain confidentiality, due to the nature of group settings, there is a possibility of inadvertent disclosure of personal information within the group. I acknowledge that this risk is inherent in a group therapy setting.

By signing below, I acknowledge that I have received a copy of the HIPAA Notice of Privacy Practices, which describes how my child’s health information will be used and disclosed. I understand my rights and the privacy practices outlined in the notice.

This consent is valid for the duration of your child’s participation in speech therapy group sessions or until it is revoked in writing. You may withdraw consent at any time.

Please ensure this form is reviewed and filled out before the first session, and ensure compliance with HIPAA regulations regarding privacy, consent, and documentation.