CONSENT TO TREAT & AUTHORIZATION TO RELEASE INFORMATION, ASSIGNMENTS OF BENEFITS.
I hereby authorize OMPT Specialists, through its appropriate personnel, to perform the evaluation and treatment procedures that are deemed necessary by the physician in the treatment of my condition. I further authorize OMPT to furnish the appropriate agencies, for the purpose of billing, any information acquired during the course of my treatment. I am assigning my therapy benefits to OMPT for the services in which I receive and authorize my insurance carrier to make payment to OMPT on my behalf. OMPT reserves the right to seek reimbursement from any and all insurers regardless of whether you provide us with their contact information, unless you instruct us to bill you directly. All records released require administrative and copying fee paid to OMPT before they are released, regardless of requestor. OMPT is HIPAA compliant with regard to information sharing policies.
ASSIGNMENT OF BENEFITS: I hereby instruct and direct my insurance company to pay OMPT Specialists for the professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payments toward the total charges for the professional services rendered.
THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional services charges over and above the insurance payment. A photocopy of this assignment shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney involved in this case. I authorize OMPT to initiate a complaint to the insurance commissioner for any reason on my behalf.
NOTICE OF PRIVACY PRACTICES:
By signing this form, you acknowledge that you received or have been provided an opportunity to review the Notice of Privacy Practices of OMPT Specialists. This Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full. Our Notice of Privacy Practice is subject to change.
Medical Information Release Form
(HIPAA Release Form)
Release of Information
I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to: