Patient Forms
CONSENT OF TREATMENT AND AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize Med Diagnostic Rehab of South Florida through its appropriate personnel, to perform or have performed upon me or the above named patient, appropriate assessment and treatment procedures relating to the diagnosis stated by my referring physician.

I further authorize Med Diagnostic Rehab of South Florida to release to appropriate agencies, any information acquired in the course of my or the above named patient's examination and treatment.


  I have read, understand and acknowledge the Consent of Treatment and Authorization to Release Information

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

PLEASE REVIEW IT CAREFULLY

The federal government passed a new law in August 1996 dealing with the privacy of patient records. The new law is called Health Insurance Portability and Accountability Act. HIPAA for short. This is our general consent form. Again review it carefully.

Health Information Uses and Disclosures

In our medical practice, we routinely record, use and disclose your health information in order to treat and to assist other healthcare providers in treating you. We also use and disclose your healthcare information in order to obtain payment for our services.

Permitted Uses and Disclosures Without Your Consent or Authorization

We may need to disclose your health information without your authorization in the following situations:

  • To contact you by telephone or mail to remind you of appointments or to respond to your questions.
  • To family members or close friends who are involved in your healthcare.
  • If we are providing healthcare se rvices to you in an emergency.
  • If there are substantial barriers in communicating with you, but in our professional judgment we believe that you intend for us to provide care.
  • For purposes of public health and safety, such as to the FDA to report defects or incidents.
  • To Government agencies for the purposes of their audits, investigations, and other oversight activities.
  • For research purposes of a limited nature in a limited manner.
  • For providing benefits under Worker's Compensation.
  • To the law enforcement authorities to assist and or apprehend criminal offenders.
  • To Government agencies for prevention of child abuse and domestic violence.
  • When required by law, search warrants, subpoenas, or court orders.

Our Privacy Pledge

We have and always will respect your privacy. We will not use or disclose your health information without your prior written authorization, other than the uses and disclosures we describe above.

Your Right To Revoke Your Authorization

You may revoke your authorization to us at any time; however, your revocation must be in writing. There are two circumstances under which we will not be able to honor your revocation request:

  1. If we have already released your health information before we received your request to revoke your authorization.
  2. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information. If they decide to contest any of your claims, your revocation authorization must be submitted to our office in writing.

Your Right to Limit Uses or Disclosures

If there are healthcare providers, hospitals, employers, or other individuals or organizations to which you do not want to disclose your information, it must be submitted in writing.

Your Patient Rights

As a patient, you have the following rights:

  • To receive a copy of the Notice of Privacy Practices.
  • To obtain access to and/or a copy of your health information.
  • To request that we communicate with you confidentially by reasonable alternative means.
  • To request how we handle or disclose your health information.
  • To request amendments to your health information.
  • To request an accounting of certain disclosures which we have made of your health information.

Should you have any questions, concerns, or complaints regarding our Privacy Practices, now or in the future, you may contact our Privacy Official, Alex Kalnitsky. She can be reached at (561) 638-1078.

You also have the right to submit a written complaint to:

The U.S. Department of Health and Human Services
Office of Civil Rights
200 Independence Avenue SW
Washington, DC 20201


  I acknowledge that I was provided a copy of the Notice of Privacy Practices from the Med Diagnostic Rehab of South Florida for me to keep and I have had an opportunity to read and understand the notice. This acknowledgement is requested per Government Statute.

PATIENT FINANCIAL POLICY AND AGREEMENT

We are committed to providing you with the best possible care. If you have insurance, we will gladly accept assignment of benefits and file all insurance claims provided verification of your insurance policies allows assigned benefits and coverage for the services rendered.

Please read the following statements carefully. By signing below you agree that you have read and fully understand all statements contained herein.

I, the undersigned, understand that Med Diagnostic Rehab of South Florida will bill my insurance carrier for the services rendered upon verification of coverage from my insurance company. I also understand that should my insurance company fail to make payment for services rendered, I am fully responsible for all charges incurred, and will pay in full for all services. I understand that I am responsible for payment of any and all deductibles, and/or co-insurance amounts and the charges incurred are not subject to any fee schedule or reductions made by my insurance carrier. I also understand that if my treatment is due to an injury which results in litigation against a third party, this in no way relieves me of my obligation to pay for the services rendered. I understand that payment of the fees are not contingent upon settlement of a litigation; however, I hereby instruct my attorney to pay Med Diagnostic Rehab of South Florida in full, directly from the proceeds from any settlement or judgment rendered on my behalf.

EXPLANATION OF MEDICARE BENEFITS

Accepting assignment means that the provider of services agrees to accept the allowable charges as determined by Medicare as full payment. However, Medicare pays 80% if the allowable charges, therefore you are responsible for the 20% balance. In addition to the 20% you are also responsible for any amounts applied toward your annual Part B deductible and any non-covered charges.

SUPPLEMENTAL COVERAGE/CO-PAYMENT

Med Diagnostic Rehab of South Florida has explained to me that under Medicare guidelines, I will be responsible for the 20% of the allowable charge. As Superior Med Diagnostic Rehab of South Florida has agreed to accept assignment of benefits on this portion of the charges also, I understand that should the supplemental insurance company fail to pay for these charges within a “reasonable length of time”, or send payment directly to me, I will become responsible for payment in full.

WORKER’S COMPENSATION COVERAGE

Med Diagnostic Rehab of South Florida agrees to treat and bill worker’s compensation for preauthorized work related injuries per the Worker’s Compensation Guidelines for the State of Florida. However, if for any reason Worker’s Compensation denies liability for the treatment of the injury, I understand that I become responsible for full payment of the charges.

AUTHORIZATION OF TREATMENT AND ASSIGNMENT OF BENEFITS

I, the undersigned, hereby consent to such treatment by the authorized personnel of Med Diagnostic Rehab of South Florid a as may be dictated by prudent medical practices of my illness, injury or condition. This consent is intended as a waiver of liability for such treatment excepting acts of negligence.

The undersigned certifies that the information given by me in applying for payment under the Title XVII of the Social Security act is correct. I, the undersigned, authorize Med Diagnostic Rehab of South Florida to release information regarding m health care to the Social Security for this or a related claim. I authorize payment form Medicare to be made directly on my behalf.

I hereby instruct and direct that my Supplemental/Commercial Insurance pay by check made out and mailed to:

Med Diagnostic Rehab of South Florida
3800 NW 2nd Avenue Ste. 5
Boca Raton, Florida 33431

The professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment is not to exceed my indebtedness to the above-mentioned assignee and I have agreed to pay any balance of the said professional service charges over and above this insurance payment.

A PHOTOCOPY OF THIS ASSIGNMENT SHALL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL.

PATIENT INFORMATION SHEET
PATIENT MEDICAL HISTORY
   
 

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