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I hereby give consent to Larry Ham & Assoc

By Danielle Pierce,2014-09-26 23:30
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I hereby give consent to Larry Ham & Assoc

    ARRY & ASSOC. L PHYSICAL THERAPY P.S. AM H

    CONSENT FORM

    ? 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

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