Protected
Health Information (Health
Information Portability & Accountability Act - HIPAA)
I
understand a copy of my rights and Restore Therapies staff's
responsibilities under HIPAA law can be made available to me upon my
request at any time.
Informed
Consent to Examine and Treat
I
give my consent to be interviewed for present and past medical
history and regarding but not limited to my chief complaint as well
as to receive a thorough physical examination relative to my chief
complaint. I agree to not withhold medical history from this
interview. I understand my physical examination may include but not
be limited to my vital signs, a visual inspection and observation of
body structures, as well a palpatory examination of such structures,
active and passive inspection of my mobility and the application of
standardized tests. I understand, although extremely rare, the
physical examination may cause some pain, aggravation of my existing
pain or bruising.
I
give my consent to receive treatment based on the findings of this
evaluation in a matter consistent with the standards of practice of
physiotherapists licensed in the State of Florida. I understand,
although extremely rare, adverse conditions may occur, including, but
not limited to, aggravation of my chief complaint, pain, soreness,
bruising, hematoma, burns, frostbites, skin tears, swelling or
fractures, except for acts of negligence on my part or Restore
Therapies staff.
Financial
Responsibility
-
Treatment
of Headaches - I
understand Restore Therapies, LLC or Armin Loges, PT will not bill
third parties or third party insurances for treatments of headaches
I consent to and receive. I understand payment is due at the time
of each treatment session.
-
All
other treatments - I
understand all other treatments (non-headache) may be billed to my
third party insurance or insurances, if such services are covered
and if I so choose. I understand I am liable for any deductibles or
co-pays at the time of each visit, as determined by my insurance. I
understand adjustments may be made by my insurance company at a
later date, in which case I may be billed or reimbursed accordingly
for any differences.
Release
of Information
I
hereby authorize my treating or referring physician to release any
medical records in their possession concerning my illness or
treatment to Restore Therapies or Armin Loges, PT as well as my
records to be released to my treating or referring physician and my
third party payer(s) upon their request.
Consent
to Photograph
Although
rarely required, photographs may assist in documenting my condition
or evaluation findings. I hereby authorize Restore Therapies staff
or Armin Loges, PT to take digital photographs of myself to be made
part of my record.
Cancellations
& No-Shows
I
understand I will be billed and agree to pay $30 for each
cancellation made with less than 24 hours notice and each no-show to
appointments I made.
Termination
I
understand I may terminate this agreement at the time of my choice.
Consents, releases, authorization for payment and financial
responsibility shall remain effective after such termination.
________________________________________
______________ __________________________
Patient
Name Date of Birth
SSN
________________________________________
______________
Patient
Signature Date
________________________________________
_______________________________ ______________
Parent
or Guardian Name (if patient is a minor) Parent or
Guardian Signature Date
