Athens Neuro & Balance Rehabilitation

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1 Acknowledgement of Receipt Of Notice of Privacy Practices Patient Name & Address: I have a received a copy of the Notice of Privacy Practices for the above named practice. Signature For Office Use Only We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because: An emergency existed & a signature was not possible at the time. The individual refused to sign. A copy was mailed with a request for a signature by return mail. Unable to communicate with the patient for the following reason: Other: Prepared By Signature

2 Authorization for Release of Information Patient Information: Name of Patient SSN of Birth Age Address, City, State, Zip Name & Address of Covered Entity Authorized to release information: Athens Neuro & Balance Rehabilitation 1088 Baxter Street, Suite C The above named entity is authorized to disclose protected health information to the entities named below. Entity to Receive Information. Initial each that is subject to this authorization. Leave information on the voice mail or answering machine. Discuss information with the following person(s): Other: Description of information to be released & time of my next appointment and with whom. Information results from any Tests, X-rays or MRI's. Medication prescribed and or refilled All of my protected health information generated by ANBR and on file in my chart. All of my financial information generated by ANBR Other information as described: This authorization shall be in force and effect until revoked by the patient or representative signing the authorization. The permitted use of the information is to inform the patient.

3 Rights of the Patient I understand that I have the right to revoke this authorization at any time by sending a written notification to: Sherri Dando, Compliance Officer 108 Park Avenue Athens, GA I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to inspect or copy the protected health information to be used or disclosed as described in this document. I can do this by written notification to: Sherri Dando, Compliance Officer 108 Park Avcnue Athens, GA I understand that my treatment will not be conditioned on signing this authorization. I understand that I have the right to refuse to sign this authorization. Signature of Patient or Personal Representative Print or Type Name of Patient or Personal Representative Description of Personal Representative s Authority (attach necessary documentation)

4 Dear Patient: Re: TEN IMPORTANT THINGS TO KNOW ABOUT POLICIES AND PROCEDURES 1. We request twenty-four hours for renewal of prescriptions. Please contact our office before your medication is completed. The doctor must review your file and record the script refill appropriately. 2. There is a nominal fee for special forms you may need completed. You may check with the staff for fees, which are payable in advance. 3. We require twenty-four hours notice for cancelled and rescheduled office appointments. We reserve a significant amount of time in our schedule and do not stack or double-book appointments. Failure to notify our office at least twenty-four hours prior will result in a $25.00 charge that the patient is responsible for. 4. Please contact our office if you need to reschedule your therapy appointment. If you miss three appointments, your time slot will be forfeited to another patient and you will be released from Athens Neuro & Balance Rehabilitation s care and recommended to follow-up with your primary care physician. 5. Children are not allowed in the Rehabilitation areas or examination rooms. 6. Our office will verify insurance information. Please note that benefits quoted by your insurance company are not a guarantee of payment. 7. We file the initial claim to your insurance company at no charge to you. We include all medical records and data when the claim is submitted. If it becomes necessary to resubmit a claim, you may be charged. 8. Your co-pays are due at the time of service unless you have made previous arrangements for a payment plan. We will be happy to bill you by mail with a $4.99 monthly processing fee added to each statement. 9. You are ultimately responsible for charges incurred regardless of the insurance s involvement. Your insurance policy is a contract between you and your insurance company. It is your responsibility to follow-up on claims that are not paid in a timely manner. 10. After 60 days, any outstanding balance on your account becomes your responsibility, and we expect payment in full at that time. The above information has been explained to me, and I understand the policies and procedures of Athens Neuro & Balance Rehabilitation. Signed

5 DATE: PLEASE RELEASE TO: Athens Neuro & Balance Rehabilitation 1088 Baxter Street, Suite C Phone: Fax: MEDICAL RECORDS AND IMAGING STUDIES FOR: NAME ADDRESS DATE OF BIRTH / / SIGNATURE Please use this form when requesting previous films (MRI s, X-rays, CT s, bone scans, etc.) and diagnostic studies. Bring or mail your reports and studies to our office on, or before, your appointment. Please understand that this is your responsibility. If you have any questions or need assistance, please contact our office Baxter Street, Suite Fax:

6 OFFICE PAYMENT POLICY We are happy to file your insurance claims for our services. Please make sure we have ALL of your current insurance information. Our office will verify insurance information. Please note that benefits quoted by your insurance company are not a guarantee of payment. After 60 days any outstanding balance on your account regardless of any insurance claim, becomes your responsibility and we expect payment in full at that time. Should this happen, we would appreciate your contacting your insurance company, as Georgia law requires either payment or a written explanation for nonpayment within 60 days of filing. If you are unable to pay your outstanding balance in full at that time, please call us to arrange monthly payments. You will be required to sign a payment plan agreement at that time. FINANCIAL AGREEMENT The undersigned agrees that in consideration of the services to be rendered to the patient, he/she hereby individually obligates himself/herself to pay the account of the clinic in accordance with the regular rates and terms of the clinic. Should the account be referred to an attorney for collection, the undersigned shall pay reasonable attorney s fees and all collection expenses. I agree to notify Athens Neuro & Balance Rehabilitation if my insurance company/coverage is cancelled or changed. Thank you. I have read and I understand the above policy and I agree to abide by these terms. Patient s Signature (Parent s signature if patient is a minor)

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