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.
I agree with all of the above statements.
Medical Information Release Form
(HIPAA Release Form)
Date Of Birth
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:
PATIENT MEDICAL HISTORY
Please check any/all conditions that apply to you:
Is this condition controlled by medication?
Is your physician aware of thisCondition?
High or Low Blood Pressure (circle one)
High or Low Thyroid (circle one)
1.What is your, Height?
What is your, Weight?
*BMI (for office use only)
2. Have you had surgery related to this injury/symptom onset? Yes No
If yes, when was it?
3. Are you currently pregnant? Yes No
4. Do you smoke? Yes No
If yes, how many packs per day?
5. Do you drink alcohol? Yes No
If yes, how often?
6. Have you undergone any previous surgeries (please include all, including date)?
7. Are you taking any medications? Yes No
8. If yes, please see attached Medication List and complete all sections.
9. If there is anything else we should know about your health, please tell us below:
Reason for medication(pain)
Dosage(Ex. 200 mg)
Route(Topical, inhalation, intravenous, oral)
Frequency(Ex. 3x per day)
Duration(Ex. As needed, 4 weeks, etc.)
**PLEASE NOTIFY YOUR THERAPIST OF ANY MEDICATION CHANGES THROUGHOUT THE DURATION OF YOUR THERAPY**
Cancel and No-show policy:
Unlike most facilities, we offer one on one care without any double booking, if you do not give us a 24-hour warning that you will not be able to make it to your scheduled appointment it becomes very costly for our physical therapists.
Therefore, if you do not give notice at least 24 hours prior to your scheduled appointment or you do not show up for your appointment a $25 charge will be added to your account and must be paid before your next scheduled appointment.
If you cancel within 24 hours but reschedule within the same week this is not considered a cancelation.
We understand that emergencies do happen, we allow for 2 emergency cancellations per month with no charge to your account.
I have read the above policy and understand I will be charged if I do not cancel my appointments 24 hours in advance.