CONSENT TO TREAT AND CONDITIONS OF ADMISSION
1 CONSENT TO REHABILITATION PROCEDURES: The undersigned consents to the procedures which may be performed during this and future out patient physical therapy visits that are performed at Baudry Therapy Center. I/We consent to examination, therapy procedures and therapy care given the patient by or under the supervision of the physical therapist.
2 LEGAL RELATIONSHIP BETWEEN FILL IN YOUR NAME HERE THERAPY PHYSICAL THERAPISTS: All Physical Therapists (PT), and Physical Therapist Assistants (PTA) are employed by Baudry Therapy Center. Baudry Therapy Center serves as a medical teaching facility; therefore, physical therapist students, physical therapist assistant students and physical therapy residents may be involved in your care under the supervision of an attending PT or PTA.
3 FINANCIAL AGREEMENT: The undersigned agrees whether he/she signs as agent or as patient, that in consideration of the services to be rendered to the patient, he/she hereby individually obligates himself/herself to pay the account of Baudry Therapy Center in accordance with the regular rates and terms of Baudry Therapy Center. All accounts are handled by our billing staff, including billing, collections and all other matters relating to the account.
4 ASSIGNMENT OF INSURANCE BENEFITS: The undersigned authorizes, whether he/she signs as agent or as patient, direct payment to Baudry Therapy Center of any insurance or other applicable (e.g., Medicare, BCBS) benefits otherwise payable to or on behalf of the undersigned or patient for these outpatient services, at rate not to exceed Baudry Therapy Center’s regular charges. It is agreed that payment to Baudry Therapy Center, pursuant to the authorization, by an insurance company shall discharge said insurance company of any and all obligations under a policy to the extent of such payment. Any pre-certification of insurance benefits is the patient’s sole responsibility; however, Baudry Therapy Center will make every effort to get this as a courtesy to the patient. The undersigned authorizes payment of Medicare benefits to be made on behalf of the patient for all services furnished by Baudry Therapy Center. It is further understood by the undersigned that he/she is financially responsible for charges not collected by this agreement, unless otherwise stated by applicable written contract or law.
5 PHOTOGRAPHING AND VIDEOTAPING: Baudry Therapy Center may photograph, film, videotape or otherwise make video and/or audio recordings of the patient only for purposes of diagnosing and treating the patient’s condition. No photograph or videotape will be used for any other purpose other than treatment without the patient’s written consent.
6 DISCLOSURE OF HEALTH INFORMATION: I understand that Baudry Therapy Center is a health provider who must comply with the Health Insurance Portability and Accountability Act of 1996. HIPAA protects the privacy of individually identifiable health information. The Baudry Therapy Center Notice of Privacy Practice outlines your rights and our responsibilities regarding your medical information and who to contact if you have any concerns regarding your medical information. Your initials below acknowledge that you have been given a copy of the Baudry Therapy Center Notice of Privacy Practices.
