PATIENT INFORMATION CONSENT FORM

 Acknowledgement

 

I, the undersigned, acknowledge that I was provided a copy of the current "Notice of Patient Information Practices" for
Farmington Hand and Physical Therapy to read and can request a copy for my own purposes upon request.

 

 

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(Print) Patient's Full Name                                                                        

 

 

 

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Patient Signature/Guardian                                                                          Witness Signature (Office use only)

 

 

 

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Today's Date                                                                                                Today's Date/Appt. Date

 

Consent

 

I have read and fully understand FARMINGTON HAND AND PHYSICAL THERAPY's Notice of Information Practices

(on reverse side). I understand that FARMINGTON HAND AND PHYSICAL THERAPY may use or disclose

my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality

of services provided and any administrative operations related to treatment or payment. I understand that I have the right

to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations

if I notify the practice. I also understand the FARMINGTON HAND AND PHYSICAL THERAPY will consider requests

for restriction on a case-by-case basis, but does not have to agree to the requests for restrictions.

 

I hereby consent to the use and disclosure of my personal health information for purposes as noted in

FARMINGTON HAND AND PHYSICAL THERAPY's Notice of Information practices.

I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.

 

I hereby assign to the above provider the medical and/or surgical benefits to which for my dependent(s) are entitled

under my health insurance plan. I agree to pay any co-pay amount required by my insurance company at time of service.

In addition, I understand I will be responsible for any remaining account balance after my insurance has paid their portion.

Such as, but not limited to, deductible, co-insurance percentages, patient responsibility portions, or any collection costs,

attorney fee and court costs, in the event that I would fail to pay my account.

 

I hereby understand the therapy treatment program, diagnosis, goals and expected outcomes will be thoroughly explained
to me by my attending therapist. I hereby agree to be treated and to cooperate as expected. 
 

 

 

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Signature:                                                                                Today's Date:

 

 

 1280 Doctors Drive, Farmington MO 63640, Phone# 573.756.2320, Fax# 573.760.8677