CONDITIONS OF ADMISSION TO COMPREHENSIVE PHYSICAL THERAPY, INC.

MEDICAL CONSENT: The patient is under the control for the attending medical service provider. Comprehensive Physical Therapy, Inc. assumes no liability for any act or omission in following the instruction(s) of said provider. The undersigned consents to any physical therapy rendered under the general and/ or special instruction of provider.

CONSENT TO RELEASE MEDICAL INFORMATION: I consent to allow Comprehensive Physical Therapy, Inc. to furnish any part of my medical record to any person, company, agency, or other authorized party responsible for all or part of my physical therapy care. By giving my consent, I understand the requester may have access to otherwise confidential information contained within my medical record. If I choose to not release my medical record information, I understand and agree I will pay for all my physical therapy charged in the even payment is denied.

SPECIAL CONSENT: I understand my medical record may contain information specific to drug/alcohol abuse and/or addiction, and/or psychiatric conditions, and/or HIV testing and/or HIV positive diagnosis. Such diagnosis and treatment may not be released without my specific consent. I consent to allow such information to be given to any person, company, agency, or other authorized party responsible for all or part of my physical therapy charges. I can withdraw my consent at any time. My consent is valid for this admission/visit only and when the billing process is complete, it lapses.

CONSENT FOR REVIEW OF MEDICAL RECORDS BY FEDERAL/STATE AGENCIES AND OTHER AUTHORIZED AUDITING AND REVIEW AGENCIES: I understand there are federal/state and other agencies who are required to review, and on occasion, copy parts of my physical therapy record for the purposes of assuring an acceptable standard of physical therapy and that charges for my physical therapy services are correct as stated. I consent to review of my medical records for these purposes alone.

IF THE PATIENT IS A MINOR OR LEGALLY INCOMPETENT TO SIGN FOR HIS/HER OWN MEDICAL CARE, THE PARENT OR LEGAL GUARDIAN MAY SIGN IN HIS/HER PLACE FOR ANY OF THE ABOVE CONSENTS.

PERSONAL ITEMS: Comprehensive Physical Therapy, Inc. will not be liable for loss or damage to any personal valuables.

FINANCIAL AGREEMENTS: The undersigned agrees, whether he/she signs as agent or patient, that in consideration of the services to be rendered to the patient, he/she hereby obligates himself/herself to pay the amount in accordance with the rates and terms of the business. Should the account be referred to an attorney or collections agency for collection and/or suit, the undersigned shall pay reasonable attorney’s fees and collection expenses.

ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize payment directly to Comprehensive Physical Therapy, Inc. of the group or personal benefits or any other insurance benefits otherwise payable to me, for this period of physical therapy care. I understand I am financially responsible to Comprehensive Physical Therapy, Inc. for charges not covered by this assignment. A photocopy of this authorization shall be considered as effective and valid as the original.

PATIENT CERTIFICATION/AUTHORIZATION TO RELEASE INFORMATION AND PAYMENT REQUEST: I certify the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information to release sufficient information regarding my diagnosis or treatment for billing purposes. I request payment of authorized benefits be made on my behalf. I assign the benefits payable for physical therapy services to the organization furnishing the services. I understand I am financially responsible to Comprehensive Physical Therapy, Inc. for charges not covered by this agreement.

NON-COVERED SERVICES: If you are a member of a HEALTH MAINTENANCE ORGANIZATION, MANAGED CARE PROGRAM, OREGON HEALTH PLAN, SAIF/MAJORIS or MEDICAID PCO, certain products and services are not covered. If the services you receive are not covered under the guidelines set by your preferred provider contract or by the Oregon Medical Assistance Program, you may be financially responsible to pay for these services.

I have reviewed a copy of the Comprehensive Physical Therapy, Inc. Notice of Privacy Practices, which describes how my health information may be used and shared and how I may obtain access to my health information. I understand that Comprehensive Physical Therapy, Inc. has the right to change this Notice at any time. I may obtain a current copy of the Notice by contacting Comprehensive Physical Therapy, Inc. at (541) 344.6446.

By signing below, I acknowledge that I have been provided a copy of the Notice of Privacy Practices.

By signing below, I acknowledge that Comprehensive Physical Therapy, Inc. needs 24 hour notice for appointment cancellation in order to fill the appointment. No shows will incur a $50 charge.

A COPY OF THE “CONDITIONS OF ADMISSIONS” FORMS IS AVAILABLE UPON REQUEST.

THE UNDERSIGNED CERTIFIES THAT HE/SHE HAS READ THE FOREGOING AND IS THE PATIENT, OR DULY AUTHORIZED BY THE PATIENT AS THE PATIENT’S AGENT, TO EXECUTE THE ABOVE AND ACCEPT ITS TERMS.

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