Client Forms

Comprehensive Privacy and Consent Agreement Form

The Comprehensive Privacy and Consent Agreement Form is required for all clients and includes health information, massage preferences, payment and cancellation policies, confidentiality and privacy practices (including HIPAA compliance), and liability waivers. It ensures your informed consent for massage therapy and acknowledgment of our Notice of Privacy Practices. First-time clients: Please print, complete, and sign the form before your appointment. Bring it with you or email it to us in advance to streamline the check-in process and help us provide personalized care.

Request for Restriction on Use/Disclosure of Protected Health Information (PHI)

This form enables clients to request specific restrictions on the use or disclosure of their protected health information (PHI) by a covered entity. It ensures compliance with HIPAA by documenting the client’s request and the entity’s decision to approve or deny the restriction.

Confidential Communication Request Form

This form enables clients to request alternative methods or locations for receiving communications about their protected health information (PHI). It helps ensure HIPAA compliance by recording the client’s preferences and the covered entity’s response to the request.

Request to Inspect or Copy PHI Form

The "Request to Inspect or Copy PHI Form" allows clients to request access to their protected health information (PHI) in specific categories and choose the preferred delivery method. It ensures compliance with HIPAA by documenting the client’s request and providing information on response timelines and potential fees.

Amendment Request Form for Protected Health Information (PHI)

The "Amendment Request Form" allows clients to request corrections or updates to their protected health information (PHI) by specifying the information they believe is incorrect or incomplete. It ensures compliance with HIPAA by documenting the request, informing clients of possible denials, and providing details on the entity’s response timeline and potential fees.

Maine Mental Health Information Disclosure Consent Form

The "Maine Mental Health Information Disclosure Consent Form" allows clients to authorize the disclosure of their mental health information to specified recipients for purposes such as coordinated care or treatment planning. It complies with both Maine state law and HIPAA by outlining the scope of the information, the recipients, the client's right to revoke consent, and the potential risks of disclosure.

Authorization for Release of Protected Health Information (PHI)

The "Authorization for Release of Protected Health Information (PHI)" form allows clients to grant permission for their medical records and other PHI to be disclosed to specified third parties, such as healthcare providers, attorneys, or insurance case managers, for a specified purpose. The form includes details on the information being released, the recipient, the purpose of the release, and the expiration of the authorization, while also outlining the client’s right to revoke consent.

Informed Consent for Treatment Form for Cupping

The Informed Consent for Treatment Form for Cupping ensures that clients are fully informed about the nature, risks, benefits, and alternatives of cupping therapy before undergoing treatment. The form also acknowledges the client’s right to withdraw consent at any time, confirming their understanding and voluntary agreement to proceed with the therapy.

Massage Therapy Complaint Form

The Massage Therapy Complaint Form allows clients to report any concerns or issues related to their massage therapy experience while ensuring that their information is handled confidentially in compliance with HIPAA and Maine State Law. The form captures details about the incident, the involved therapist, and desired resolution, ensuring a transparent process for addressing complaints.

Accounting of Disclosures Request Form

The Accounting of Disclosures Request Form allows clients to request a detailed report of the disclosures of their Protected Health Information (PHI) made by the massage therapy practice within a specified time period, up to the past 6 years. The form ensures that clients can track how their PHI has been shared, providing transparency and compliance with HIPAA and Maine State Law.

Maine Patient Rights and Responsibilities Notice

This form outlines the rights and responsibilities of patients receiving services at Thrive Bodyworks, including respectful care, informed consent, privacy, access to health records, and grievance procedures, with contact information for the Maine Division of Massage Therapy. It also emphasizes the practice's commitment to maintaining a safe, sanitary environment and provides guidelines for patient conduct, accurate health disclosures, payment, and appointment management.

Privacy Policies 2024

The Notice of Privacy Practices (NPP) for Thrive Bodyworks LLC outlines how your Protected Health Information (PHI) may be used or disclosed in compliance with HIPAA and Maine state laws, detailing your rights and our responsibilities regarding privacy and confidentiality. This document also explains procedures for reporting data breaches, filing complaints, and accessing or amending your health records, ensuring transparency and client protection.

Health Screening Form for COVID-19 and Communicable Diseases

The Health Screening Form for COVID-19 and Communicable Diseases is a precautionary tool to assess the health and exposure risk of clients before their appointment. It includes questions about recent symptoms, close contact with infected individuals, travel history, vaccination status, and any recent positive test results. This form helps ensure the safety of clients and staff by identifying potential health risks and allowing the massage therapist to make informed decisions about proceeding with appointments. Clients certify the accuracy of their responses through a signed acknowledgment.