FAMILY PHYSICAL THERAPY & WELLNESS CENTER
Patient Consent:
TO OUR PATIENTS: Please read and sign the form below. Ask questions if you do not understand.
Please check to indicate approval:
____RELEASE OF MEDICAL RECORDS FOR MY MEDICAL CARE OR AS REQUIRED BY LAW.
To health care providers directly involved in my care.
To state, federal, and accrediting bodies for required reporting data and/or surveys for compliance.
For purposes of my care and for business operation.
Note: Records are not automatically sent to your physician. They must be requested.
____ASSIGNMENT OF BENEFITS/BILL MY INSURANCE:
I AUTHORIZE Family Physical Therapy & Wellness Center to send my bills for my medical care and treatment to my insurance company and/or Medicare or Medicaid for payment, to the extent my insurance company and/or Medicare or Medicaid is required to pay the bill under terms of my insurance policy or by law.
I request that my insurance company and/or Medicare or Medicaid pay Family Physical Therapy & Wellness Center of the providers who are involved in my treatment. I consent to the release of my medical records by Family Physical Therapy & Wellness Center to my insurance company and/or Medicare or Medicaid (and organizations working on their behalf) if necessary in order for my bills to be paid.
I agree to pay for charges not covered by insurance.
I understand that if I do not check this box Family Physical Therapy & Wellness Center will send a bill directly to me for payment.
____RELEASE OF MEDICAL RECORD FOR MEDICAL OR SCIENTIFIC RESEARCH:
I agree that my records my be used by Family Physical Therapy & Wellness Center for medical or scientific study.
No information, which can identify me as a patient, in any such study will be shared. I may revoke this in writing at any time.
By signing this form, I consent and authorize my medical health provider to assess and treat me. I understand that my provider is available to explain the purpose of treatment, and that I have the right to refuse recommended treatment. I understand I have the right to revoke this consent, in writing, at any time except where Family Physical Therapy & Wellness Center has already made disclosures in reliance on the consent.
Date___________________ PATIENT’S DATE OF BIRTH________________________
SIGNATURE OF PATIENT/AUTHORIZED REPRESENTATIVE______________________
PRINT NAME_________________________________
IF AUTHORIZED REPRESENTATIVE, RELATIONSHIP TO PATIENT_____________
Check only if applicable (one time acknowledgement)
_____I acknowledge that I have been offered a copy of Family Physical Therapy & Wellness Center’s Privacy Practices information, if I would like a copy in the future, I will ask for one.
General Patient Information for Family Physical Therapy Wellness Center
Patient Last Name_______________________ First Name & M.I.____________________________
If child under 18 – Name of Parent or Guardian___________________________________________
Address_____________________________ City_______________ State_____ Zip______________
Home Phone _______________Work # ____________________Cell #________________________
Sex: M F Soc. Sec. #:_____________________ Date of Birth:__________________________
Employed: Full Time Part Time Retired Student: Full Time Part Time
Employer:____________________________ Type of Work: ______________________________
Circle One: Single Married If Married, Spouse’s Name:__________________________________
Spouse’s Employer: ______________________Emergency Contact: _________________________
Emergency Contact Phone #:____________________Referred By___________________________
Primary Doctor: _____________________________Primary Clinic__________________________
Commercial Insurance ONLY
Company Name________________________________ Policy #:____________________________
Insured’s Name________________________ Group #_________________________________
Insured’s Employer_______________________ Insured’s Date of Birth ______________________
Relation to Insured __Self __Spouse __ Dependent Insurance Co-Pay __________________
Medicare Insurance
Insured’s Name_______________________________ Date of Birth________________________
Policy #__________________________
Automobile or Worker’s Compensation ONLY
**Please note that if this is an AUTOMOBILE ACCIDENT, Minnesota is a NO FAULT state, so you need to file the claim with your auto insurance company and give us your auto insurance information.
**Please note that if this is a WORKER’S COMPENSATION claim, you must notify your employer immediately, if you have not done so already. Your employer will give you the insurance company name and contact information.
Insurance Company: ________________________Claim # _____________Policy #______________
Agent’s Name____________________________ Adjuster’s Name____________________________
Billing Address___________________________ City______________ State____ Zip____________
Phone # ___________________Fax #____________________ Date of Incident ________________
Assignment
_____ I agree to pay my insurance co-pay at the time care is received.
_____ I agree to pay for all supplements and supports at the time received.
_____ I understand and agree that my health insurance policy is a contract between my insurance company and myself. If the insurance company denies payment of
benefits or they have been exhausted, I understand that I am personally
responsible for my account.
_____ I acknowledge cancellations must be made 24 hours in advance or I will be charged a $25 cancellation fee.
I understand and agree to everything I have signed and authorize Family Physical Therapy to contact my attorney, third party insurance, or any other applicable insurance company regarding my case for billing and/or benefits and/or settlement information.
Patient Signature ________________________________________ Date ___________