Healthcare BLT Rx Template

HEALTHCARE BLT RX TEMPLATE

Patient Information

Patient Name: Date of Birth:

Phone: Email:

Gender: Male Female Other / Prefer not to say

Insurance Information

Policy / ID Number: Group Number:

Medical History

Prescribing Clinician Order (BLT)

Clinician Name: Clinic / Practice:

Diagnosis / Indication:

Special Instructions / Precautions:

Risks, Benefits and Alternatives

I understand that the BLT therapy ordered above (Bilateral Lower Extremity Therapy) is intended to reduce pain, improve function and mobility. The anticipated benefits include improvement in strength, range of motion, gait, and reduction of symptoms. Potential risks and complications include, but are not limited to: transient or persistent pain, increased swelling, bruising, skin irritation, allergic reaction to topical agents or adhesives, muscle or tendon strain, aggravation of symptoms, and rare unforeseen complications. There is no guarantee of complete resolution of symptoms. I have had an opportunity to ask questions about risks and benefits and have received satisfactory answers.

Alternatives to the proposed therapy were explained to me and may include: observation, medications, injections, assistive devices, surgical consultation, or other conservative modalities. I understand that I may refuse or withdraw consent at any time prior to receiving therapy; withdrawal must be made in writing to the treating clinician or the clinic administration and does not affect care already provided.

Authorization for Use and Disclosure of Protected Health Information

I hereby authorize the release of my medical information necessary to carry out treatment, obtain reimbursement, and for health care operations related to the BLT therapy. This authorization includes disclosure of medical records, diagnostic results, treatment notes, and billing information to the clinician, treating facility, and my insurance payer as needed. I understand that my health information may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations, except where state law is more protective.

I acknowledge that I have been offered a copy of the practice's Notice of Privacy Practices that explains my rights with respect to my protected health information. By signing this form I expressly authorize use and disclosure as described above.

Financial Responsibility and Billing Authorization

I authorize the named provider and its billing agents to submit claims for services rendered under this order to my insurance carrier(s). I understand that I am financially responsible for any copay, deductible, coinsurance, and services not covered by my insurance. If my insurer denies payment, I accept responsibility for payment in accordance with the clinic's billing policy. I certify that the information I have provided is true and accurate to the best of my knowledge.

Patient Acknowledgment and Consent

By signing below I certify that I have read (or have had read to me) and understand the contents of this BLT Rx and Consent form. I understand the nature of the proposed therapy, the anticipated benefits, material risks and alternatives, and I consent to receive the ordered BLT therapy. I authorize the clinic and treating clinicians to provide the care as ordered and to share my information for treatment and billing purposes as described above.

Sign Now