Consent to Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations Acknowledgement of Notice of Privacy Practices
I understand that as part of my health and medical care, Northern Therapy and Rehabilitation, Inc. originates and maintains medical and health records describing my health history, symptoms, examinations, and test results, diagnoses, treatment, and any plans for future care of treatment. I further understand that this information serves as:
a)A basis for planning my care and treatment
b)A means of communication among healthcare professionals who contribute to my care
c)A source of information for applying my diagnosis and treatment to my bill
d)A means for a third party payer to verify that the services billed were actually provided
e)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. This agreement to release information shall remain in force until such time as I shall revoke it in writing.
I understand that I have the right to request written copy of Northern Therapy and Rehabilitation, Inc’sPATIENT PRIVACY NOTICE that provides a more complete description of information uses and disclosures and that I had the right to review the PATIENT PRIVACY NOTICE prior to singing this consent. I understand that Northern Therapy and Rehabilitation, Inc. reserves the right to change their notices and practices, but prior to implementation will make available a copy of the revised notice. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and Northern Therapy and Rehabilitation, Inc. is not required to agree to the restrictions requested. I understand that I must revoke this consent in writing, except to the extent the organization has already taken action to reliance thereon.
I, ______, have been given the opportunity to review Northern Therapy and Rehabilitation, Inc’s. Notice of Privacy with an effective date of April 14, 2003.
______I give Northern Therapy and Rehabilitation, Inc. permission to share information regarding my medical care to the following: ______
______
______I give Northern Therapy and Rehabilitation, Inc. permission to leave a message regarding my appointment time or changes in my appointment schedule with household members or on my home or cell voicemail or answering machine.
Signature of Patient ______Date ______
Signature of Witness ______Date ______
Name of Witness ______
Consent for Care and Treatment
The undersigned Patient (or Parent or Guardian of the Patient) hereby gives consent to NORTHERN THERAPY AND REHABILIATION, INC. (“NORTHERN THERAPY”) to provide such medical care and treatment as may be necessary and proper in diagnosing or treating my physical condition. I understand that I have the right as a patient to refuse all or part of the treatment or activities proposed by the clinic’s staff throughout the course of my treatment. I will promptly advise the therapist and clinic staff of any changes in my physical condition or medication during the course of treatment at NORTHERN THERAPY. I will ask NORTHERN THERAPY for reasonable accommodations that may be necessary for me to communicate my needs, understand my rights, or receive treatment.
X______
PATIENT/GUARDIANDATE
Payment-Assignment of Claims and Benefits-Grant of Lien
I assign all medical benefits I may receive because of my treatment at NORTHERN THERAPY. This includes Medicare, Worker’s Compensation Benefits, and medical insurance under individual or employer sponsored plans or policies, whether they are for an individual or group. Furthermore, I grant NORTHERN THERAPY a lien and security interest upon all claims I have or proceeds that may be recovered as a result of personal injury claims made arising from the injuries for which I am being treated by NORTHERN THERAPY, including claims against my own insurance company. This lien and security interest is to secure payment of all sums due for such treatment and NORTHERN THERAPY may give notice of this lien and security interest to those individuals, insurance companies, and entities that are or may become directly or indirectly liable to me for those injuries. I authorize NORTHERN THERPAY to make claims for payment from others, and further authorize the release of all information necessary to secure payment, including medical records.
NORTHERN THERAPY will bill my insurance as a courtesy, although I am responsible for the entire bill when services are rendered and my insurance information is not a guarantee of payment. The co-payment must be made on the date of each service. I will make arrangements with the business office if I cannot pay my deductible in full today. If my insurance company has not paid my bill within 60 days, I will pay those unpaid amounts. If I receive payment from my insurance company directly I will promptly send those funds to NORTHERN THERAPY. All overpayments will be refunded to me or to the party making payment, as the case may be.
If my treatment arises from an injury for which Worker’s Compensation benefits are payable, I understand that I may be responsible for the charges if the claim is contested.
I agree to pay costs of collection, attorney’s fees, collection costs, and skip tracing expenses in the event my account is referred to a collection agency or attorney. The individuality of any right granted to NORTHERN THERAPY herein will not affect the remaining provisions.
I understand a medical lien could be placed on my MVA and liability account.
X______
PATIENT/GUARDIANDATE
I have read and understand this information, and have had the opportunity to ask for an explanation of any terms that I do not understand.
X______
PATIENT/GUARDIANDATE