Healthcare Rehabilitation Agreement

HEALTHCARE REHABILITATION AGREEMENT

Patient Information

Date of Birth:    Gender:

Emergency Contact

Relationship:    Phone:

Insurance Information

Medical History

Treatment Plan and Services

Estimated Duration:    Frequency:

Risks, Benefits and Alternatives

I acknowledge that the rehabilitative treatments described above have potential benefits including improved function, reduced pain, and increased independence. I understand that risks can include, but are not limited to, increased pain, muscle soreness, soft tissue injury, exacerbation of symptoms, and rare complications related to manual techniques or physical exertion. Alternative options may include no treatment, home exercise only, medication management, or referral to another specialist.

I acknowledge that these risks and benefits have been explained to me and that I have had the opportunity to ask questions.

Patient Rights; Withdrawal of Consent

I understand that I have the right to refuse or discontinue treatment at any time, and that doing so may affect the outcome of care. I further understand that discontinuation does not relieve me of financial responsibility for services already rendered.

I understand my right to withdraw consent and request modification or termination of treatment.

Financial Responsibility and Assignment

I agree to be financially responsible for services provided. I authorize the facility to bill my insurance, and to release information necessary for claims. I understand that I am responsible for co-payments, deductibles, coinsurance, and amounts not paid by my insurer.

I assign benefits to the provider and authorize payment of insurance benefits to the provider when permitted by contract.

Cancellation, No-Show, and Collections

The patient must provide advance notice for cancellations. Repeated missed appointments may result in discharge from the program. Outstanding balances not resolved within the stated timeframe may be referred to collections and I will be responsible for collection costs, attorney fees, and court costs where permitted.

Cancellation notice required (hours):

Privacy, Records Release and HIPAA Acknowledgment

I acknowledge that I have been provided notice of privacy practices and that the provider may use and disclose my protected health information for treatment, payment, and health care operations as permitted by law. I authorize release of medical records related to treatment to my insurer or designated parties as necessary for payment and coordination of care.

Authorization expiration date:    (If left blank, authorization expires upon completion of care or one year from signature, whichever occurs first.)

Telehealth / Alternative Modes of Care

I consent to receive services via telehealth or remote modalities when clinically appropriate. I understand the limitations of telehealth and that in-person care may be recommended.

I consent to telehealth services when offered by my provider.

Acknowledgments and Consents

By signing below I certify that the information provided is accurate to the best of my knowledge, I consent to the rehabilitative services described in this agreement, I authorize release of information as described, and I accept financial responsibility as stated.

Consent to treatment

Consent to insurance billing and assignment of benefits

Consent to release medical information as necessary for payment and care coordination

Miscellaneous Provisions

This agreement constitutes the entire understanding between the patient and provider regarding rehabilitation services. Any amendment must be in writing and signed by the patient and an authorized representative of the provider. To the extent permitted by law, disputes arising under this agreement shall be governed by the laws of the state in which services are provided.

If signer is a legal guardian or authorized representative, state relationship:

Sign Now