Consent for Treatment, Payment & Healthcare Operations

Your signature on this form indicates you consent to the following arrangements:
I. I consent to the use or disclosure of my protected health information by Body in Balance Physical Therapy, LLC for the purpose of:
   1. diagnosing or providing treatment to me
   2. obtaining payment for my health care bills
   3. to conduct health care operations of Body in Balance Physical Therapy, LLC

   I understand that diagnosis or treatment of me by my therapist may be conditioned upon my consent as evidenced by my signature on this document.

   My “protected health information” means health information, including my demographic information, collected from me and created or received by my therapist, another health care provider, a health plan, my employer, or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

II. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of this practice. Body in Balance Physical Therapy is not required to agree to the restrictions that I may request. However, if Body in Balance Physical Therapy agrees to a restriction that I request, the restriction is binding on Body in Balance Physical Therapy.

   I have the right to revoke this consent, in writing, at any time, except to the extent that my therapist or Body in Balance Physical Therapy has taken action in reliance on this consent.

III. I understand I have the right to review Body in Balance’s Notice of Privacy Practices prior to signing this document. Body in Balance’s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payments of my bills, or in the performance of health care operations of Body in Balance Physical Therapy. The Notice of Privacy Practice is also posted at our Hartland office site. This Notice of Privacy Practice also describes my rights and Body in Balance Therapy’s duties with respect to my protected health information.

   Body in Balance Physical Therapy, LLC reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent to me in the mail or by asking for one at the time of my next appointment.

IV. I understand the cost of my therapy will be billed to the appropriate payer; i.e. Medicare, private insurance, or workers compensation. I understand any amounts not paid by my insurance remain my responsibility.

V. I authorize payment of any insurance benefits to be sent directly to Body in Balance Physical Therapy, LLC.