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340 Plaza Rd •
4080 Route 28 •
Mon-Thur 8-7 • Fri 8-5 • Closed Weekends
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Hand Therapy HIPPA Notice/Consent Form
Authorization for Treatment:
The person named below (hereinafter called "patient"), consents that Kingston Physical-Occupational Therapy and Sports Rehab, P.L.L.C., its health care providers, clinical and technical employees or any assistants, whom they may call to their aid, may administer any treatment deemed advisable in the care and treatment of the patient.
Assignment of Benefits:
The patient and/or insured requests that payment of any existing insurance benefits is made on their behalf to all providers of service during this encounter. The patient understands that it is necessary for Kingston Physical-Occupational Therapy and Sports Rehab, P.L.L.C. to release certain medical information in order to receive payment of its debt from the third party insurers or governmental "providers".
Terms of Financial Agreement:
The patient agrees to pay all charges made by Kingston Physical-Occupational Therapy and Sports Rehab, P.L.L.C. or other service providers for services rendered to the patient. Any portion of the bill not covered by insurance or other benefit is due in full at the time of services unless prior arrangements have been made. The patient understands that insurance is a contract between the subscriber and the insurance company and that Kingston Physical-Occupational Therapy and Sports Rehab, P.L.L.C. will bill the insurance carrier as a courtesy to the patient. The patient agrees to pay all collection fees arising from noncompliance with this contract.
No Show/Cancellation Policy:
Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Therefore, Kingston Physical-Occupational Therapy and Sports Rehab, P.L.L.C. reserves the right to charge a fee of 25.00 for all missed appointments (“no shows”), or cancellations without 24-hours notice. This fee is not covered by insurance and must be paid prior to your next appointment.
HIPAA Acknowledgement/Consent Notice Written Authorization:
I acknowledge receipt of Kingston Physical-Occupational Therapy and Sports Rehab, P.L.L.C. Notice of Privacy Practices. I give consent to Kingston Physical Therapy & Sports Rehab, P.C. to obtain or disclose my protected health information for the purpose of treatment, payment or health care operations. I give my consent to Kingston Physical-Occupational Therapy and Sports Rehab, P.L.L.C. to leave messages about my appointments at my home on my answering machine or with another party as designated by myself. Should I choose to change my authorization I will contact Kingston Physical-Occupational Therapy and Sports Rehab, P.L.L.C. by writing.
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