Common use of Authorization for Release of Information Clause in Contracts

Authorization for Release of Information. The institution rendering services is hereby authorized to furnish and release, in accordance with facility policy, such professional and clinical information as may be necessary for the completion of my medical claims by valid third-party agents or agencies from the medical records compiled during treatment. The facility rendering treatment is hereby released from all legal liability that may arise from the release of said information. I also authorize the release of any and all medical records from other facilities requested by the above entity, as may be required for completion of the therapist's chart review, assessments, and evaluations. After 90 days, a new signed Release of Information is required. Financial Responsibility We participate in most major health insurance plans. As a courtesy to our patients, we will submit insurance claims to your carrier and verify your plan benefits. We expect you to: • Be responsible for understanding the details of your insurance coverage, including requirements for pre- authorization, annual deductible, co-pay, or co-insurance amounts, and visit or dollar limitations for physical therapy services. • Provide us with a current copy of your insurance card(s) and notify us of any changes in your insurance coverage. If we do not have current insurance billing information, we will expect full payment at the time of service. Our Business Office team will verify coverage with your insurance carrier; this is, however, no guarantee of benefit. Some plans have a set co-pay per visit; some require you pay a co-insurance percentage, after satisfying your plan- year medical deductible. We expect you to: • Be responsible for any charges not paid by your insurance company within 60 days of our filing. • If your plan has a co-pay per visit, payment is due at time of service, per our contract with your insurance. • If your plan has a medical deductible which has not yet been satisfied, a minimum deposit of $100 is due at the time of service. • If your plan has a co-insurance per visit, an estimated amount will be determined, and payment is encouraged at time of service which applies as a credit to your account. This prevents you receiving a large billing once the insurance has completed processing several claims. We mail patient statements each month after insurance has processed any claims. • If any durable medical equipment (DME) is recommended by your provider, we do not bill your insurance for these items. If you choose to purchase any DME, payment is required at time of service.

Authorization for Release of Information. The institution rendering services is hereby authorized to furnish and release, in accordance with facility policy, such professional and clinical information as may be necessary for the completion of my medical claims by valid third-party agents or agencies from the medical records compiled during treatment. The facility rendering treatment is hereby released from all legal liability that may arise from the release of said information. I also authorize the release of any and all medical records from other facilities requested by the above entity, as may be required for completion of the therapist's chart review, assessments, and evaluations. After 90 days, a new signed Release of Information is required. Financial Responsibility We participate in most major health insurance plans. As a courtesy to our patients, we will submit insurance claims to your carrier and verify your plan benefits. We expect you to: • Be responsible for understanding the details of your insurance coverage, including requirements for pre- authorization, annual deductible, co-pay, or co-insurance amounts, and visit or dollar limitations for physical therapy services. • Provide us with a current copy of your insurance card(s) and notify us of any changes in your insurance coverage. If we do not have current insurance billing information, we will expect full payment at the time of service. Our Business Office team will verify coverage with your insurance carrier; this is, however, no guarantee of benefit. Some plans have a set co-pay per visit; some require you pay a co-insurance percentage, after satisfying your plan- year medical deductible. We expect you to: • Be responsible for any charges not paid by your insurance company within 60 days of our filing. • If your plan has a co-pay per visit, payment is due at time of service, per our contract with your insurance. • If your plan has a medical deductible which has not yet been satisfied, a minimum deposit of $100 is due at the time of service. • If your plan has a co-insurance per visit, an estimated amount will be determined, and payment is encouraged at time of service which applies as a credit to your account. This prevents you receiving a large billing once the insurance has completed processing several claims. We mail patient statements each month after insurance has processed any claims. • If any durable medical equipment (DME) is recommended by your provider, we do not bill xxxx your insurance for these items. If you choose to purchase any DME, payment is required at time of service.