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AUTHORIZATION AND RELEASE

I understand that the information that I have given today is correct to the best of my knowledge.  I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status or insurance policies.  I authorize the Allied Rehab staff to bill and receive payments from my insurance company.  My insurance coverage is an agreement between me and my insurance company.  I am fully responsible for all charges.   Should this become a collection issue, I assume all costs of collection including but not limited to court costs, interest, and legal fees.

___________________________ ____/____/____ ________________________

              Signature of Insured                               Date                      Signature of Witness

TREATMENT CONSENT

I consent to therapy considered necessary for the treating of my diagnosis.  I also permit the release of any information to or from my therapist as may be required by my physicians, workers comp., or insurance carriers.  I agree to assume full financial responsibility for the cost of my therapy treatment which is otherwise not paid by my insurance company.

___________________________  ____/____/____  _______________________

  Signature of patient, Parent, or Guardian                    Date                                Signature of Witness

NO-SHOW POLICY

I agree to pay Allied Rehab $25.00 for each no-show or cancelled visit unless I give at least a 2 hour notice. I further understand that Allied Rehab is not allowed to bill my third-party payer or worker’s comp. carrier for this no-show fee, and that I am fully responsible for this fee.

_______________________ ____/____/____ ____________________________

         Signature of patient                                     Date                           Signature of Witness