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ONE STOP Physical Therapy & Wellness
3300 Hamilton Mill Road, Suite 102-271
Buford, Georgia 30519
Phone or Fax:  770-888-9504
Email:  info@onestopphysicaltherapy.com

 

RELEASE OF INFORMATION AND CONSENT FOR TREATMENT

I am aware of my diagnosis and give permission to receive treatment from One Stop Physical Therapy, Wellness and Home Safety (Provider) clinician(s).

I give permission to Provider and its affiliates to release information, verbal and written, contained in my medical record, and other related information, to my insurance company, rehabilitation nurses, case managers, attorneys, employers, school, related healthcare providers, assignees and/or beneficiaries, and all affiliates to obtain medical records and/or professional information from my physician/provider or other medical professionals as it relates to my treatment.

ASSIGNMENT OF BENEFITS

I give my permission to bill Medicare and/or any other insurance or private entity and authorize payment directly to Provider and its affiliates for services.  This is a direct assignment of my rights and benefits under this policy.  A photocopy of this assignment shall be considered as effective and valid as the original.

NOTICE OF PRIVACY PRACTICES (HIPPA ACKNOWLEDGEMENT CONSENT)

I hereby acknowledge that I have reviewed the HIPPA Privacy Rule.  I heaereby consent to the use and disclosure of my prsonal health information for the purposes of treatment, payment and healthcare operations.  HIPPA Privacy Rule can be found at http://www.hhs.gov/hippa/for-professionals/privacy/laws-regulations/index.html

PAYMENT GUARANTEE

Financial responsibility for all services, treatments and equipment provided by the Provider is the sole responsibility of the client receiving these treatments or their POA.  Provider accepts Medicare, cash, check, credit cards or transfers from the apps listed below, but is out of network for commercial health insurers.  The Provider will work with the Client/POA to determine possible insurance reimbursement for care rendered, but the ultimate responsibility for payment rests with the Client/POA, not their insurance company.  I am responsible for all deductibles, co-insurance and non-covered services.  I agree to pay to the order of One Stop Physical Therapy, Wellness and Home Safety for services rendered.  The Provider will collect full cash payment of co-pay at the end of each visit or period rendered if exact amount is specified by the insurance.  If client has co-insurance, whether client responsibility is a percentage of the bill and not an exact amount, the Client/POA will be billed after reimbursement is received from Medicare or insurance.  Please understand that our clinicians have to travel to you, so if you cancel a visit in less than 24 hours, our clinicians cannot see another client, therefore a fee of $75 will be applied to you, unless the cancellation is an emergency (ie: unscheduled trip to MD, hospital, death in family, etc.)

Please select your preferred payment method(s) from the list below:

Thank you for your effort!  All information is needed to perform the best service possible.

By entering your name above, you agree to use of electronic signature

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