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1 Today s Date: / / / / Full Legal Name (First, Middle, Last) Date of Birth Age Social Security Number Marital Status Address City State Zip Out of State Address Phone: Home ( ) - Cell ( ) - PREFERRED WAY TO CONTACT YOU FOR APPOINTMENT REMINDERS: HOME PHONE CELL PHONE Emergency Contact: Phone: ( ) - NAME/RELATION IF PATIENT IS A MINOR, RESPONSIBLE PARTY MUST COMPLETE THIS SECTION. IF NOT A MINOR SKIP THIS SECTION Full Legal Name (First, Middle, Last) RELATION TO PATIENT: MOTHER RESPONSIBLE PARTY INFORMATION / / Date of Birth FATHER OTHER: INSURANCE INFORMATION ARE YOU AWARE OF YOUR BENEFITES FOR YOUR INSURANCE? YES NO Primary Insurance: Insured Name/Date of Birth: Secondary Insurance: Insured Name/Date of Birth: ACCIDENT INFORMATION Was this injury the result of an accident? YES NO DATE OF ACCIDENT/INJURY: MOTOR VEHICLE ACCIDENT WORK RELATED OTHER Workers Compensation Adjuster (if applicable): Claim Number: Attorney Information (if applicable): Referring Doctor: Please notify our office of any changes to your information listed on this form.

2 CONDITIONS AND CONSENT FOR TREATMENT/FINANCIAL RESPONSIBILITY CONSENT FOR THERAPY SERVICES Consent is given to Robert Volski and Associates and its employees to provide Physical Therapy and/or Occupational Therapy services and administer physician orders. Therapists are responsible for explaining all Physical Therapy and/or Occupational Therapy procedures. The undersigned authorizes observers to be present during treatment for purposes of training and education. AUTHORIZATION TO RELEASE INFORMATION The undersign authorizes Robert Volski and Associates to release medical and/or other information about the patient, which may be necessary for the completion of insurance claims, review of services, or receipt of benefits. Such information may include current medical records. The information may be released to third-party payors, including the third-party payor s agent and/or representatives or anyone responsible for payment of therapy charges. ASSIGNMENT OF BENEFITS The undersigned assigns and authorizes direct payment of benefits (including insurance benefits, otherwise payable to the patient) to Robert Volski and Associates. The undersigned agrees to assist in processing claims for benefits. MEDICARE AUTHORIZATION I certify the information given by me in applying for payment under Title XVII of the Social Security Act id correct. I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administrator or its Intermediaries or carriers any information needed for this or a related Medicare claims. I request the payment of authorized benefits be made on my behalf to Robert Volski and Associates. FINANCIAL RESPONSIBILITY The undersigned agrees to pay for therapy services rendered to patient and is hereby obligated to pay all accounts of patient to Robert Volski and Associates. It is understood and agreed that reasonable cost of collection including attorney fees, collection agency fees, and/or open accounts interest charges assessed are payable by the undersigned. To the extent not expressly prohibited by applicable law, the undersigned agrees to pay all therapy charges not paid in full to Robert Volski and Associates by a third-part paylor. Robert Volski and Associates accepts cash, personal checks, MasterCard, and Visa as forms of payment. The undersigned is aware that in some cases the insurance company may not cover the patient s therapy bill in full. The undersigned is aware of the fact that he/she (patient/responsible party/guarantor) is responsible for any balance insurance does not pay. This balance due may include provisions set by your insurance such as: co-payments, deductibles and usual and customary allowances. Co-payments and deductibles are due when services are rendered. I ACKNOWLEDGE THAT I HAVE READ THIS FORM AND UNDERSTAND ITS PURPOSE AND CONTENT. X Guarantor (Agreement to Pay) Date Clinic Representative CONSENT FOR TREAMTNET OF A MINOR X Patient/Guardian/Responsible Party Signature (Consent to Treat) As parent and/or legal guardian, I authorize Robert Volski and Associates to treat the minor patient named in the attached forms while I am not present. Date Parent/Guardian Signature: Date:

3 NOTICE OF PATEINT INFORMATION PRACTICES Robert Volski and Associate s Legal Duty Robert Volski and Associates are required by law to maintain the privacy of your personal health information, provide this notice about our information practices, and follow the information practices that are described herein. Uses and Disclosures of Health Information Robert Volski and Associates uses your personal health information primarily for treatment; obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example, Robert Volski and Associates may use your personal health information to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you. Robert Volski and Associates may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law. In any other situation, Robert Volski and Associate s policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time. Robert Volski and Associates may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room, patient exam areas and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time. Patient s Individual Right s You have the right to review or obtain a copy of your personal health information at any time. You have the right request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes. You may request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. A request for restrictions or limitations must be placed in writing. Robert Volski and Associates will consider all such requests on a case-by-case basis, but the practice is not legally required to accept them. Concerns and Complaints If you are concerned that Robert Volski and Associates may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our practice manager at the address listed below. You may also send a written complaint to the US Department of Health and Human Services. For further information on Robert Volski and Associate s health information practices or if you have a complaint, please contact: Robert Volski and Associates Robert Volski Kenwood Lane, Suite 56 Fort Myers, Florida By signing this form I acknowledge that I have received a copy of the HIPPA Notice of Information Practices from Robert Volski and Associates and understand it completely. Signature Date

4 PATIENT INFORMATION CONSENT FORM I have read and fully understand Robert Volski and Associate s Notice of Information Practices. I understand that Robert Volski and Associates may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I also understand that Robert Volski and Associates will consider requests for restrictions on a case-by-case basis, but does not have to agree to requests for restrictions. I hereby consent to the use and disclosure of my personal health information for purpose as noted in Robert Volski and Associates Notice of Information practice. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time. [PLEASE CHECK BOX THAT APPLIES] I hereby authorize release of any or all of the following personal health information to my primary care or family physician(s). These records include, but are not limited to; initial evaluation, plan of care, progress notes and discharge summary. I DO NOT authorize release of any of my personal health information to my primary care or family physician(s). I give consent for the therapist/receptionist to leave a message on my: CELL / HOME / WORK / regarding future appointments? Please circle one or more. I give consent for the therapist/receptionist to leave a message on my: CELL / HOME / WORK / containing medical information? Please circle one or more. MY SIGNATURE REPRESENTS MY ACKNOWLEDMENT AND UNDERSTANDING OF THE INFORMATION PRESENTED TO ME ON THIS FORM. Print Name Patient/Guardian Signature Date

5 CANCELLATION & NO-SHOW POLICY We require a 24 hour notice in the event of a cancellation. Please have an alternative time in mind to insure that you will receive the prescribed number of treatments. A $25 fee will be charged for appointments cancelled with less than 24 hour notice and for no show or missed appointments. This fee is not billable or payable by insurance. Patients with more than three missed appointments will be referred back to their physician. We understand that emergencies do occur and will attempt to make reasonable accommodations for that. Thank you for your cooperation. I have read this document and fully understand my responsibilities. Patient/Guardian Signature: Date: Effec. Date 8/14/2014

6 CONSENT FOR TREAMTNET OF A MINOR As parent and/or legal guardian, I authorize Robert Volski and Associates to treat the minor patient named in the attached forms while I am not present. Parent/Guardian Signature: Date:

7 12734 KENWOOD LANE, SUITE 56 FORT MYERS, FLORIDA (239) (239) AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION Complete all sections of this Authorization as appropriate to your request. Patient Name: Birth Date: (Full Legal Name) Address: Phone #: (street address) WHO (city) (state) (zip code) I hereby authorize Robert Volski and Associates to take the following action. ACTION REQUESTED (check one) Provide a copy of my medical records to me Release my medical records to: (street address) (name of other person and/or entity) (city) (state) (zip code) (fax number) What For this Authorization, my medical records means (check one or more): Evaluation / Plan of Care Treatment Notes Discharge Summary Total bill for services rendered Other (please specify) This authorization does NOT include records from other healthcare providers that are a part of your medical records with Robert Volski and Associates. WHY Page # 1 of # 2 Copy Medical Records Copy Patient / Representative Effec. Date 8/14/2014

8 At my request For my healthcare / treatment For legal purposes For payment / insurance purposes Other: I understand that: This Authorization is voluntary. My treatment will not be impacted, no matter if I sign this Authorization or not. This Authorization is valid for one year from date signed, unless I revoke/withdraw this Authorization or unless an earlier date is specified here:. I may revoke/withdraw this Authorization, except to the extent that action has been taken prior to receipt of the revocation/withdrawal, by mailing or faxing a written request along with a copy of the original Authorization to the clinic where the Authorization was made or given. Once my health information is disclosed as requested, it may no longer be protected by federal and state privacy laws, and could be re-disclosed by the person(s) receiving it. Signature of Patient Only: Date: / / (Required) If you are NOT the patient but are signing on behalf of the patient, please complete below I,, am the (check which applies) (print your name) Parent with Parental Rights Court Appointed Guardian Legally Appointed Healthcare Agent Medical Power of Attorney Power of Attorney with Right to See Medial Records Court Appointed Personal Representative of Deceased Representative s Signature: Date: / / (Required) Address: Phone: You MUST attach proof of your authority to act on behalf of the patient as checked above (other than parent). Page # 2 of # 2 Copy Medical Records Copy Patient / Representative Effec. Date 8/14/2014

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