Healthcare Rehab Agreement

HEALTHCARE REHAB AGREEMENT

This Healthcare Rehabilitation Agreement (the Agreement) is entered into by and between Patient Name: and Provider Name: . The parties agree as of Effective Date: Month Day Year .

Patient Information

Month Day Year

Male    Female    Other / Prefer not to say

Insurance and Billing

Medical History (Relevant)

Scope of Services

Provider agrees to furnish rehabilitation services to Patient as clinically indicated, which may include physical therapy, occupational therapy, speech therapy, pain management, functional training, assistive device evaluation, and related rehabilitative modalities (Services). Services to commence on: Month Day Year .

Financial Terms & Authorization

Patient is responsible for payment for services as set forth below. Provider will bill Patient's insurance as a courtesy; however, Patient remains ultimately responsible for all charges not covered by insurance, including co-payments, deductibles, and services denied as not medically necessary.

By signing below, Patient authorizes Provider to submit claims to Patient's insurance and to receive payment directly from the insurer for covered services. Patient authorizes Provider to use and disclose protected health information as necessary for treatment, payment, and health care operations.

Patient authorizes Provider to release and obtain medical records and information to/from other healthcare providers and payers as necessary for continuity of care and billing. This authorization expires on: Month Day Year .

Consent for Treatment; Risks and Acknowledgements

Patient understands that rehabilitation services may involve physical exertion, manual techniques, electrical modalities, exercise, and use of equipment. Potential risks include, but are not limited to, muscle soreness, increased pain, falls, fracture, allergic reaction to materials, or other unforeseen complications. Provider has explained anticipated benefits and material risks and alternatives.

I acknowledge that I have had the opportunity to ask questions about my care and that no guarantees have been made regarding results. I understand I may withdraw consent for treatment at any time, subject to any applicable discharge procedures and billing obligations.

Acknowledgment of Risks and Consent: I consent to receive the rehabilitation services described above and accept the risks identified.

Privacy and HIPAA Acknowledgment

Patient acknowledges receipt of Provider's Notice of Privacy Practices describing how protected health information is used and disclosed for treatment, payment, and health care operations. Patient consents to electronic and telephone communications for appointment reminders and billing unless otherwise requested in writing.

Acknowledgment of Privacy Notice: I acknowledge receipt of the privacy notice and authorize communications as described.

Termination; Cancellation; Emergencies

Either party may terminate this Agreement for convenience upon written notice. Provider may discharge Patient for noncompliance, missed appointments, or unsafe behavior. Provider maintains emergency procedures and will make reasonable attempts to contact Patient's emergency contact if Patient experiences a medical emergency during care.

Liability; Indemnification; Governing Law

Provider will exercise reasonable care and clinical judgment in the provision of Services. Patient releases Provider from liability for ordinary negligence to the extent permitted by law and agrees to indemnify Provider for claims arising from Patient's failure to follow instructions or disclosure of inaccurate medical history. This Agreement shall be governed by the laws of the state selected below.

Acknowledgements & Patient Responsibilities

Patient agrees to follow prescribed home programs, notify Provider of changes in medical condition, attend scheduled appointments, and provide accurate insurance and demographic information. Failure to follow recommendations may reduce effectiveness of treatment and may result in termination of services.

Representations and Signatures

Each person signing this Agreement represents and warrants that he or she is authorized to enter into this Agreement on behalf of the party identified, that all information provided is true and correct, and that no further corporate, legal, or familial approvals are required to bind the party.

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