ARRY & ASSOC. L PHYSICAL THERAPY P.S. AM H
? I have completed the previous information to the best of my knowledge.
? I, ______________________, do hereby agree and give my consent for Larry
Ham & Assoc. Physical Therapy to provide physical therapy services considered
necessary and proper in assessing and treating his/her condition.
? I hereby give consent to Larry Ham & Assoc. Physical Therapy to use and
disclose my protected healthcare information for the purpose of treatment,
payment, and health care business functions. A detailed Notice Of Privacy
Practices has been made available to me.
? I understand that it is my responsibility to verify my insurance benefits and
limitations and to provide current and correct insurance information to Larry Ham
& Assoc. Physical Therapy.
? I authorize Larry Ham & Assoc. Physical Therapy to bill my insurance carrier and
request that payment be sent directly to the provider. If my insurance carrier
sends payment to me, the patient/responsible party, I agree to forward the
payment on to Larry Ham & Assoc. Physical Therapy within 5 days of receipt.
? For those patients that are considered Worker’s Compensation be advised that if
your claim is denied or closed during the course of treatment, you may be held
responsible for the total amount of charges for services rendered to you.
? Co-payments are due at the time of service. Third party auto insurance cases are
the patient’s responsibility unless an attorney agreement is arranged. All patient
responsible portions overdue by 60 or more days are subject to an interest rate of
1% per every 30 day period. All patient responsible portions overdue by 90 days,
with no payment, will be turned over to collections. All returned checks are
subject to the maximum fee allowed by law.
? If you are unable to keep your appointment, please notify us at least 24 hours in
advance. If we are unavailable please leave us a message on our voice mail.
Patient/Responsible Party/Guardian Signature Date
If NOT Self, Relationship to Patient