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1 Welcome to RehabXperience. Thank you so much for choosing us. We recognize that you have a choice of physical therapy centers and greatly appreciate you for choosing us as your outpatient physical therapy center of choice. The law requires us to request your authorization and consent prior to providing you with care. Enclosed please find the following forms for your review: Authorization for Evaluation and Treatment, Consent to the Use or Disclosure of Protected Health Information (PHI), Patient Financial Responsibility, Assignment of Insurance Benefits, and Cancellation and No Show. Please review these documents. Please fill in the information in the provided spaces and sign and date each of the documents. Please do not hesitate to draw our attention should you have any question. Please hand the complete documents to our office professional. We strive on providing exceptional service and outstanding clinical results and welcome the opportunity to serve you. Sincerely yours,
2 Authorization for Evaluation and Treatment I, the undersigned, hereby authorize RehabXperience, LLC (RehabXperience) - its employees, independent contractors, and business associates - to perform physical therapy evaluations and treatments on me (or on the Patient, if I am the Legal Guardian of the patient) as related to the care planned for me. I understand that RehabXperience will provide therapy that may involve risk of injury. I realize that no guarantees have been made to me in relation to the examination, care, or treatment. I understand that I have the right to request an explanation of risks and benefits from services provided. I understand that RehabXperience is not legally responsible for the acts and omissions of its independent contractors. Signature: Date: (MM/DD/YYYY) Rev. 06/10
3 Consent to the Use or Disclosure of Protected Health Information (PHI) I, the undersigned, consent to the use or disclosure of my PHI by RehabXperience, LLC (RehabXperience) for the purposes of evaluating or providing treatment to me, obtaining payment for my health care bill or to conduct health care operations and in accord with it Notice of Privacy Practices. I understand that evaluation or treatment of me by RehabXperience may be contingent upon my consent. I understand I have the right to request a restriction as to how my PHI is used or disclosed to carry out treatment, payment or healthcare operations. I understand that if I restrict the disclosure of my PHI to insurance companies and other responsible parties, payment for services rendered will be due at the time of service. My PHI means, in part, my demographic information, collected from me and created or received by RehabXperience, other health care providers, health plans and/or my employer. This PHI relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. RehabXperience is not required to agree to restrictions on the use or disclosure of my PHI that I request. However, if RehabXperience agrees to a restriction that I request, the restriction is binding on RehabXperience. I have the right to revoke this consent, in writing, at any time, except to the extent that RehabXperience has taken action in reliance on this consent. I understand I have the right to review RehabXperience Notice of Privacy Practices prior to signing this document. The RehabXperience Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my PHI that will occur in my treatment, payment of my bills or in the performance of health care operations of RehabXperience. It also describes my rights and RehabXperience duties with respect to my PHI. RehabXperience reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by contacting RehabXperience and requesting that a revised copy be sent to me by regular mail or or by asking for one at the time of my next appointment. Signature: Date: (MM/DD/YYYY)
4 Patient Financial Responsibility Dear Patient, We are here to serve you; to facilitate your way to physical recovery and better quality of life. We are here also to assist you with finding out what financial obligations you may be assuming in connection with our treatment. Nonetheless we highly recommend that learn and understand, prior to your visit, what your insurance plan benefits are and what your responsibility for deductibles, co-insurance, or co-payment amounts may be. Not all services are covered under all insurance policies. Furthermore, benefits and coverage rules and policies differ among insurers and even between different plans of the same insurer. Either if you have insurance coverage to pay your medical bills or if your insurance plan does not cover a service or a procedure, you are ultimately responsible for full payment of charges. To find out what your insurance plan covers and what your financial obligation may be, you may call the customer service or member services department of your insurance company (the phone numbers are usually on your insurance card). You are responsible to notify us of your insurance. You are also responsible to notify us immediately of insurance changes, if any. To effectively help you meet this obligation have your current insurance card with you at the time of your visit, as well as a photo ID such as a driver's license, military ID, or government issued ID. It is also your responsibility to know your insurance company's patient responsibilities and procedures. If proper procedures are not followed, your insurer may decline payment and you may be liable for full payment of the bill. If your insurance plan requires a referral and/or prior authorization, let our office know it prior to your visit. If prior authorization is required but not obtained by the time of your visit you either may not be seen for your scheduled visit, or you will be responsible for full payment of your bill at time of service. Check all that Apply: Read Understood and Agreed Signature: Date: (MM/DD/YYYY)
5 Assignment of Insurance Benefits I, the undersigned, agree for the direct payment to RehabXperience, LLC (RehabXperience) of any insurance benefits payable to or on behalf of me including, but not limited to, Medicare, commercial insurer, Personal Injury Protection (PIP), or other auto and liability insurance covering me, or any party liable to me. I further understand that if I receive any insurance payments directly from my insurance carrier or any other liable party covering me for services rendered by RehabXperience, I will immediately (within 5 days) pay over such payments to RehabXperience. (initial) I understand that if I restrict the disclosure of my Protected Health Information (PHI) to insurance companies and other responsible parties, payment for services rendered will be due at the time of service. My PHI means, in part, my demographic information, collected from me and created or received by RehabXperience, other health care providers, health plans and/or my employer. This PHI relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I understand that charges not covered by this assignment including, but not limited to, co-pays and deductibles and due RehabXperience are payable at the time of service. Signature: Date: (MM/DD/YYYY)
6 Cancellation and No Show I, the undersigned, recognize that the effectiveness of treatment and the pace of improvement are significantly affected by the consistency and continuity in treatment. I also understand that disruption in treatment may adversely affect the outcomes of my therapy. I understand that I need to make every effort to keep the schedule of treatments as communicated to me by RehabXperience, LLC (RehabXperience). I understand that I am responsible to arrive on time to my scheduled appointments. I further understand that I am responsible to contact RehabXperience at least 24 hours prior to an appointment I cannot make to give a cancellation notice and reschedule my appointment. I am aware that RehabXperience reserves the right to charge me $25 for each noshow or late cancellation should I fail to meet my responsibility to give a notice as described above. While RehabXperience does not desire for me to incur additional expenses, this amount will cover some of RehabXperience resources that are idle as a result of my late cancellation or no-show. I understand that this fee is my responsibility, will not be billed to my insurance company and is payable upon my following visit. Following a no-show, RehabXperience may make a reasonable effort to contact me. Should the effort by RehabXperience to maintain my treatment routine fail, RehabXperience will contact my referring physician and recommend discharge for non-compliance. Relation to Patient (check one): Self Signature: Date: (MM/DD/YYYY)
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