(Financial Responsibility/Credit Policy) (Important Read Carefully) In our continuing efforts of improve the efficiency of our financial operations, we wish to explain the management of our delinquent accounts. As the vast majority of our patients are responsible and reliable in reconciling their accounts in a timely fashion, this information may be unnecessary for the most of you. However, it is our responsibility to ensure that all our patients are aware of our financial policies. Accordingly, we ask that you read the following policy statement and indicate your understanding and acceptance of its terms by signing in the space indicated below. I understand that as part of my health and medical care, Fusion Physical Therapy originates and maintains medical and health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I further understand that this information serves as: a basis for planning my care and treatment; a means of communication among the health professionals who contribute to my care; a source of information for applying my diagnosis and treatment information to my bill; a means for a third-party payer to verify that services were billed as actually provided; and a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals. I further understand and agree that this agreement to release information shall apply to all information accumulated up to this date and to any information acquired in the future. If you have any questions or concerns regarding this policy, please call our business office at (580) 699-5455. I (We) understand and accept the terms of the above outlined financial policy and will abide by the stated terms. Signature (Patient): (Printed) Date: Signature (Spouse, Guardian, Responsible Party): (Printed) Date: Witness( Office Use ): (Printed) Date: (Physical Therapy Consent to Treat) I do voluntarily consent to the treatment that has been recommended by my physician. Further I acknowledge that no guarantees have been made to me regarding the outcome of this treatment, which I have authorized I understand that as part of my health and medical care, Fusion Physical Therapy originates and maintains medical and health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I further understand that this information serves as: a basis for planning my care and treatment; a means of communication among the health professionals who contribute to my care; a source of information for applying my diagnosis and treatment information to my bill; a means for a third-party payer to verify that services were billed as actually provided; and a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals. I further understand and agree that this agreement to release information shall apply to all information accumulated up to this date and to any information acquired in the future. I do voluntarily consent to the treatment that has been recommended by my physician. Further, I acknowledge that no guarantees have been made to me regarding the outcome of this treatment, which I have authorized. I understand that as part of my health and medical care, Oklahoma Physical Therapy originates and maintains medical and health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I further understand that this information serves as a basis for planning my care and treatment; a means of communication among the health professionals who contribute to my care; a source of information for applying my diagnosis and treatment information to my bill; a means for a third-party payer to verify that services were billed as actually provided; and a tool for routine healthcare operations such as assessing the quality and reviewing the competence of healthcare professionals. I further understand and agree that this agreement to release information shall apply to all information accumulated up to this date and to any information acquired in the future. By Oklahoma law we are required to notify you…. that the information authorized for release may include records which may indicate the presence of a communicable disease which may include, but is not limited to, diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS). I hereby assign to Oklahoma Physical Therapy, all payments for medical all services rendered to me or my dependents. I understand that I am responsible for payment of my account(s) and that this document does not release me from that obligation. I understand that I am ultimately responsible for understanding and complying with the requirements of my insurance carrier including but not limited to co-payments, deductibles, precertification/recertifications for services provided, non-covered services/supplies, disputed worker compensation claims, etc., and will be held responsible for portions of my bill not covered by my insurance (including charges associated with canceled or missed appointments. A 24-hour notice is required in the event of cancellation. It is the patient’s responsibility, when they call to have an alternative time in mind that will ensure they get the full prescribed number of treatments. A $25 fee for DFancellation without proper notice and $50 fee for a no-show will be imposed and will NOT be covered by insurance, including workers’ compensation and will be the sole responsibility of the patient. Co-payments, co-insurance and /or deductible payments will be due at the time of service. I authorize any credit balance to be distributed at the discretion of Oklahoma Physical Therapay. It is the patients responsibility, when they call to have an alternative time in mind that will ensure they get the full prescribed number of treatments. I authorize my assignment of benefits to be paid directly to Oklahoma Physical Therapy. I understand I am financially responsible to Oklahoma Physical Therapy for services not authorized and/or not covered by the insurance company. I authorize the release of any medical or other information necessary to process claims. I understand all of the above and hereby state that the information is correct to the best of my knowledge. My signature indicates that I have read the above and grant the request of consent/authorizations. If you have any specific questions or concerns regarding this policy, please call our business office at (580) 699-5455. I (WE) UNDERSTAND AND ACCEPT THE TERMS OF THE ABOVE-OUTLINED FINANCIAL POLICY AND WILL ABIDE BY THE STATED TERMS. Signature (Patient): (Printed) Date: Witness( Office Use ): (Printed) Date:
