VISITOR CHECK-IN FORM

GAME CHANGER THERAPY

Visitor Confidentiality Acknowledgment Form

Game Changers Therapy is committed to protecting the privacy and confidentiality of all patients in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

As a visitor to our practice, you may see or hear information about patients, their families, or their treatment. This information is protected by law, and it is essential that all visitors respect the privacy of every patient.

Visitor Responsibilities

  • Any information I may see, hear, or otherwise learn while at Game Changers Therapy is confidential.
  • I will not share, repeat, photograph, record, or otherwise disclose any patient information.
  • I understand that failure to maintain confidentiality may result in being asked to leave the clinic and could carry legal consequences.
  • I understand that my role as a visitor does not permit access to patient records or private health information.
  • I agree to respect the rights and privacy of all patients and families at Game Changers Therapy.

Confirmation

I have read and understand the confidentiality expectations outlined above. By signing below, I agree to maintain the confidentiality of all patients and families at Game Changers Therapy.

Visitor Information & Signature

Enter a 10-digit US phone. We use this to match check-in/check-out.