1. I have presented myself to this facility for therapy treatments and consent to diagnostic procedures and care provided by my attending Therapist.
2. I give authorization to be treated within the therapy clinic areas not totally private of other patients/personnel.
3. I understand that if I do not attend therapy for two weeks or miss three consecutive appointments that I am subject to discharge. Once I have been discharged, I understand that I will need new physician’s order/referral for any further therapy and will be receiving a new evaluation.
4. Champion Rehab may disclose all or any part of my records to any party or organization responsible for all or part of my therapy charges. Champion Rehab may disclose all or part of my record to other health care providers including but not limited to, hospitals and physicians. I further agree Champion Rehab may release all or any part of my record to any federal, state, or local government body when, in the opinion of Champion Rehab such bodies may be liable for all or part of my charges in relation to my care and treatment pursuant to statute or rule.
5. I, the patient, am ultimately responsible for payment of my account. As a courtesy, Champion Rehab Outpatient Clinic will bill my insurance company on my behalf. I am responsible for paying any deductible and/or co-payment due at time of service. After 60 days, any balance not paid by insurance may become my responsibility.
I have read and fully understand the above consent form and any questions I had have been answered to my satisfaction.1. I have presented myself to this facility for therapy treatments and consent to diagnostic procedures and care provided by my attending therapist.
2. I give authorization to be treated within the therapy clinic areas not totally private of other patients/personnel.
3. I understand that if I do not attend therapy for two weeks or miss three consecutive appointments that I am subject to discharge. Once I have been discharged I understand that I will need new physician’s order/referral for any further therapy and will be receiving a new evaluation.
4. I hereby authorize the release of medical information necessary to process my insurance and authorize payment directly to the provider of service and FULLY UNDERSTAND THAT I AM FINACIALLY RESPONSIBLE for any services not covered by this authorization. **WORKERS COMPENSATION** I hereby authorize my rehab consultant to receive my records related to my work injury.
5. I have reviewed the HIPPA Privacy Policy.
I have read and fully understand the above consent form and any questions I had have been answered to my satisfaction.