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consent to care and treatment

I, the undersigned, do hereby agree and give my consent to Champion Performance Physical Therapy to

furnish medical care and treatment to considered necessary and proper by my physician in diagnosing or treating my physical condition.

Patient/Guardian: Date:

benefit assignment/release of information

I, hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled, for any and all services provided by my therapist including Medicare, private insurance and third party payers to Champion Performance Physical Therapy. A photocopy of this assignment is to be considered as the original. I, hereby authorize said assignee to release all information necessary, including Medical Records, to secure payment.

Patient/Guardian: Date:

notice of health information practices

I have been provided a notice that describes how medical information about me may be used and disclosed, and how I can get access to this information. I understand this notice and its contents and am aware of my rights as defined in the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA).

Patient/Guardian:______________________________________Date:________________________

agreement with financial policy statement

I understand and agree that my therapist bills my insurance carrier solely as a courtesy to me. I understand that I am responsible for the entire bill when services are rendered. I understand Amber Hasenmyer, MSPT will require payment of my estimated share of the services to be rendered today. If my insurance carrier does not remit payment within 60 days, the balance will be due in full from me. In the event my insurance company requests a refund of payment from my therapist, I understand I will be responsible for the amount for money refunded to my insurance company and I agree to pay all amounts. In the event my insurance company establishes an internal usual and customary schedule, I understand I will be responsible for the difference between those amounts and the costs of the services rendered.

If any payment is made directly to me for services billed by my therapist, I agree to promptly remit it to Champion Performance Physical Therapy.

I understand that this policy does not apply if I am qualified to receive Worker’s Compensation. However, I understand that if I claim Workers’ Compensation benefits and are subsequently denied such benefits, I will be responsible for the total amount of charges for services rendered to me.

I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, I will be responsible for all cost of collecting monies owed, including court cost, collection agency fees and attorney fees.

estimated insurance benefits:

Estimated patient payment:______________________________________________

Arrangements for payment of patient’s share:      __________________________      

Patient/Guardian/Responsible

Party: Date:

Champion Performance PT Rep:

_____________________________________ Date: ______

There will be a $25 fee charged for each no show/late cancellation.

NOTE: Estimated coverage information is provided as a courtesy to my patients, but is not intended to release them from total responsibility for their account balance. You are responsible for paying any no show/late cancellation fees.

The above information has been read and explained to me.

I UNDERSTAND MY RESPONSIBILITY FOR THE PAYMENT OF MY ACCOUNT.