CONSENT TO TREATMENT
I consent to rehabilitation and related services at: REVOLVE PHYSICAL THERAPY. In doing so, I understand, acknowlege and affirm that such rehabilitation and related services may involve bodily contact, touch and/or direct contact of a sensitive nature.
TREATMENT OF MINORS
I, as a parent/guardian of a minor receiving treatment hereunder, do hereby agree and understand that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resukting from failure to do so.
I know and agree that REVOLVE PHYSICAL THERAPY is not responsible for loss or damage to personal valuables.
WAIVER AND RELEASE
I hereby release, discharge and acquit: REVOLVE PHYSICAL THERAPY its agents, representatives, affiliates, employees, or assigns, of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive, or allow emergency and or medical services including but not limited to ambulance service, Emergency Medical Technician, physician urgent care or services.
AUTHORIZATION OF PAYMENT
I hereby assign all benefits directly to: RESOLVE PHYSICAL THERAPY. I also authorize release of any medical records to other healthcare providers as necessary to facilitate my treatment and to other third parties as necessary to process medical claims and otherwise premitted or required in the Notice Of Privacy Practices.
I understand fully that, in the event my insurance company or financially responsible party does not pay for the services I receive, I will be financially responsible for payment. To assist in establishing your account, please:
- Supply all necessary informatoin for accurate billing of your claim, including your insurance card, drvier's license, employer information, and demographic information.
- Satisfy all insurance co-payments, co-insurance, deductibles, and non-covered services on the day services are rendered.
- Provide your insurance company and us with any additional information requested to complete the processing of claims filed on your behalf.
I certify that all of the information provided herein is true and correct.