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consent forms
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consent forms - April 24, 2007 4:03:00 AM
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wamaciar
Posts: 9
Joined: October 18, 2006
Status: offline
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I was just wondering if anyone had a consent to treat form for outpatient PT that they would be willing to share. Thanks,
Wendy
Performance Physical Therapy
Saratoga Springs, NY
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Re: consent forms - April 24, 2007 9:17:00 AM
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yarringtonpt
Posts: 112
Joined: July 4, 2006
From: Waynesville, NC
Status: offline
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Wendy:
Here is a form -
CONSENT FOR TREATMENT
I, the undersigned, a patient at _____, do hereby authorize ____________ to administer treatment as is necessary. I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. Furthermore, I understand that as a courtesy _________ will prepare insurance forms and bill my insurance company directly. I hereby request assignment of payment of all insurance benefits to ___________. I am ultimately responsible for payment of all services rendered, unless otherwise provided by law.
DEDUCTIBLES/PERCENTAGE PAYS AND/OR CO-PAYMENTS
Co-payments are to be paid at time of service, unless prior arrangements have been made with _________________. Deductible and percentage payment amounts will be billed at the time the payment from your insurance company is received. Payment is due within 30 days of the date on the invoice. Patients agree to make every effort to keep payments current.
CANCELLATION/NO-SHOW POLICY
I understand that cancellations should be made within 24 hours prior of their scheduled time, unless extenuating circumstances prevent otherwise. I understand that two no-shows may result in my discharge from physical therapy.
NOTICE OF PATIENT INFORMATION PRACTICES
Additionally I confirm that I have (PLEASE CIRCLE) RECEIVED OR DECLINED a copy of ________ Notice Of Patient Information Practices.
I have read and fully understand _________ Notice of Information Practices. I understand that ______________ may use or disclose my personal health information for the purposes 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 ___________________ will consider requests for restriction on a case by case basis, but is not bound by law to agree to requests for restrictions.
I hereby consent to the use and disclosure of my personal health information for purposes as noted in __________________ Notice of Information Practices. I understand that I have the right to revoke this consent by notifying the practice in writing at any time.
_____________________________________________________________________
Patient or Legal Guardian’s Signature
_____
Date
_____________________________
Eric Yarrington, PT, MPT, OCS
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Re: consent forms - April 25, 2007 3:55:00 AM
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wamaciar
Posts: 9
Joined: October 18, 2006
Status: offline
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Thanks Eric! This is helpful.
I was just wondering what the Notice of Information Practices is?
Wendy
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Re: consent forms - April 25, 2007 4:27:00 AM
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yarringtonpt
Posts: 112
Joined: July 4, 2006
From: Waynesville, NC
Status: offline
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It is your HIPPA compliance statement; how your company protects the patient's confidential info.
_____________________________
Eric Yarrington, PT, MPT, OCS
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