Ultimate Physical Therapy Patient Information Form Page 5

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Consent for Treatment
I, me the undersigned, do hereby agree and give consent to Ultimate Physical Therapy to
furnish medical care and treatment considered necessary and proper in diagnosing or
treating my physical condition.
Release of Information
I permit Ultimate Physical Therapy to disclose all or part of my medical records to any person,
corporation, or agency when required for the collection of benefits or payment of
Ultimate Physical Therapy’s charges.
HIPPA-Notice of Privacy Acknowledgement
Ultimate Physical Therapy has made their Notice of Privacy Practices available to you. Your
name and signature on this page acknowledges that you were given the option to view and
receive a copy of this notice.
Guarantee of Account
For all services rendered and billed by Ultimate Physical Therapy, I hereby agree to pay the
full bill for all charges which are not paid to Ultimate Physical Therapy by insurance carriers,
Worker’s Compensation, No-Fault, or any balance due which is not covered by insurance or
excluded by a co-insurance clause.
Insurance Billing
Ultimate Physical Therapy will be submitting charges to your insurance carrier for services
rendered. As a result, you will be receiving an “Explanation of Benefits” (EOB) statement from
your insurance carrier. This is not a bill, but rather an explanation of the charges submitted
and how they were processed. There are insurance companies that will not supply the
provider with such details of the claim status, they will only speak to the patient or plan
member. It is extremely important as the patient, to work with Ultimate Physical Therapy to
obtain the reimbursement, to insure that you will not be billed for the charges that your
insurance carrier should have paid. In the event you receive a check with a copy of your EOB,
please make a copy of the EOB for our records and forward that and the check over to our
office. If you receive a denial or a statement asking for medical records or letter of medical
necessity, please contact the office immediately so that Ultimate Physical Therapy can have the
claims processed correctly on your behalf.
Patient/Guardian____________________________________________Date________________

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