Consent for Treatment
I hereby authorize PHYSICAL THERAPY SOUTH, INC and its employees to render therapy in accordance with my physician’s orders or direct access and accepted standards of practice for physical, occupational or speech therapy. I consent to abide by the established plan of care determined by the therapist including termination of therapy services at my request, physician’s request and/or the request of PHYSICAL THERAPY SOUTH, INC.
Assignment and Instruction for Direct Payment to Health Provider
I hereby instruct the above named insurance company/companies to pay by check/virtual credit card made out to and mailed directly to: PHYSICAL THERAPY SOUTH, INC for professional/medical expenses allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for services rendered.
THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY.
This payment will not exceed my indebtedness to the above mentioned assignee and I agree to pay, in a current manner, any balance of said professional fees for non-covered services and/or fees, over and above the insurance payment as required by my insurance policy.
Patient Financial Responsibility
PHYSICAL THERAPY SOUTH, INC appreciates the confidence you have shown in choosing us to provide you with therapy services. The services you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full of our fees. As a courtesy, we will verify your coverage and bill your insurance carrier. However, you are ultimately responsible for payment of your bill.
You are responsible for payment of any deductible and co-payment/co-insurance as determined by your contract with your insurance carrier. Our staff will provide you with an estimate of your cost for each date of service visit. We expect these payments to be made at the time of service and recommend you leave a credit/debit/HSA card on file with our office.
In the event our staff does not collect the full amount due by you at the time of service, you will receive a statement in the mail. You are responsible for payment upon receipt of the statement or for contacting our billing company to set up an acceptable payment plan.
I have read, understand, and agree to the provisions of this Patient Financial Responsibility.
Medical History Information
Orthopaedic History/Other – Please give dates & treatments received:
NOTICE OF PRIVACY RIGHTS
PHYSICAL THERAPY SOUTH, INC
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Notice of Privacy Practices
I hereby authorize that I am aware of my rights as it pertains to HIPAA and my Protected Health Information (PHI). PHYSICAL THERAPY SOUTH, INC has offered me a copy of their Notice of Privacy Practices for my own records.
If there is anyone you would like to authorize the disclosure of your PHI, medical or billing, you may specifically name the party below and indicate what information you would like disclosed:
For security reasons, we ask that you please do not transmit any sensitive patient data over the website contact form. Let us know a time and phone number that we can reach you.
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