Patient Forms

Prior to your appointment please complete the following forms and bring them to your appointment in order to expedite your visit.

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Download the necessary form(s), complete the required information, and print.
Please bring completed forms to your appointment.

Patient Information and Medical History

Authorization for Release of Personal Health Information (HIPAA)

Records Release

THERAPY

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost. Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.

You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.
If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers,

email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059

10DLC Terms and Conditions

“By agreeing to these terms and conditions you agree to receive automated marketing and informational SMS text messages from Omni Therapy Solutions. These messages may include appointment reminders, payment reminders, and other information related to your account or services with us. The frequency of these messages will vary depending on the purpos. You may opt out of these messages at any time by unsubscribing or informing us directly at 803-567-3348. Standard message and data rates may apply. You acknowledge that you have read and understood our Terms and Conditions and Privacy Policy.”

"By submitting this form, I consent to receive SMS text messages from Omni Therapy Solutions for appointment reminders, marketing messages, and general two-way communication. Msg frequency varies. Msg&data rates may apply. Reply HELP for support. Reply STOP to opt out."

"Consumer information is not shared with third-parties for marketing purposes"

Terms and Conditions (Terms of Service)

Effective Date:12/23/2024

By opting in to receive SMS messages from Omni Therapy Solutions (“we,” “us,” “our”), you agree to the following terms:

1. SMS Messaging Service: By providing your phone number, you consent to receive SMS messages, including updates, promotions, and other relevant content.

2. Message Frequency: You will receive up to 30 messages per month.

3. Message and Data Rates: Message and data rates may apply based on your mobile carrier’s terms.

4. Privacy Policy: Your information will be handled in accordance with our Privacy Policy, which can be viewed at [Insert Privacy Policy Link].

5. Opt-Out Instructions: You can opt out at any time by replying “STOP” to any SMS message. You may also contact us directly at 803.567.3348

6. Liability: We are not responsible for any charges, errors, or delays in SMS delivery caused by your carrier or third-party service providers.
By opting in, you confirm that you are the owner or authorized user of the phone number provided and that you are at least 18 years old.

Privacy Policy

Effective Date: 12/23/2024

Omni Therapy Solutions (“we,” “us,” “our”) respects your privacy and is committed to protecting your personal information. This Privacy Policy explains how we collect, use, and share information when you opt in to receive SMS messages from us.

Information We Collect
When you opt in to receive SMS messages, we collect:
• Your phone number
• Consent to send SMS messages

How We Use Your Information
We use your information to:
• Send you the SMS messages you’ve opted in to receive
• Provide updates, promotions, or other relevant content based on your preferences

Sharing Your Information
We do not share your phone number or SMS opt-in information with third parties for marketing purposes.

Your Rights
You can opt out of receiving SMS messages at any time by replying with “STOP” to any message we send you.

Data Security
We implement reasonable measures to protect your personal information from unauthorized access or disclosure.

If you have questions or concerns about our privacy practices, contact us at 803.567.3348