Ortho Intake Form

I hereby authorize and consent to treatment provided by Motivate, employees or designees and authorize medical services, diagnostic procedures as deemed necessary or advisable by the caregiver(s) providing treatment. I understand that no guarantee has been made as to the results of the care or treatment, which may be given to me.

Notice of Privacy Practices provides detailed information about how the practice may disclose my confidential information. Statement of Privacy Practices will be included in my Patient Take Home Folder. I understand I may request Statement prior to attending my appointment. I understand that Motivate has reserved the right to change their privacy practices and a copy of any Revised Notice will be provided to me or made available.

Evaluation reports and/or clinical information is automatically sent to your referring provider. Any other records for any other reason will not be released without a completed and signed records release form from you.

I hereby authorize payment to be made directly to Motivate for insurance benefits payable to me. I understand that I am financially responsible to Motivate for any covered or non-covered services, as defined by my insurer, which are not paid by my primary or secondary insurer. I understand I am financially responsible for payment in full if no required referral is received by this office. I understand that I am financially responsible for any collection fee and any reasonable attorney’s fees and other costs incurred for collection including but not limited to 1 ½% interest per month on any outstanding amounts unpaid 90 days after insurance resolution. I understand that I am financially responsible for a returned check for any reason and a $25.00 NSF fee. I understand that I can be terminated from the practice for monetary reasons or non-compliance with medical advice.

I understand a courtesy insurance benefits quote may be provided to me. I understand this courtesy quote is not a guarantee of benefits and for accurate details regarding my benefits I should contact my plan administrator, health benefits coordinator or other designated agent. I also understand I may be required to sign an agreed upon payment policy based on findings from courtesy benefits quote. Self Pay Program payments are due at the time of service. The Adult/Guardian who brings a Minor will be responsible for any designated payments.

If I do not have my current insurance card(s) for any date of services, I will be billed as a Self Pay. Motivate might not be able to back date from the time of service to when I do present my current insurance card(s) to Motivate. I may be asked to seek reimbursement from my insurance carrier(s).
MEDICARE Patient’s Certification, Authorization to Release Information and Payment Request. I certify that the information given by me in applying for payment under TitleXVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf directly to Motivate.

I have read the Agreement and Authorization form and I understand its contents and that I have had an opportunity to discuss its contents to my satisfaction. I understand that my signature represents agreement with the contents of the form and that any statement may not amend to contents of the form. I understand that the records/information released will not be further disclosed for any purpose other than as stated in this Authorization.