CONSENT FOR TREATMENT
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-NPP
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.
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
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.
ASSIGNMENT OF INSURANCE BENEFITS/REFERRALS/PAYMENTS GUARANTEE/COLLECTION FEE/NSF FEE
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 MY INSURANCE CHANGES OR I HAVE NO CURRENT INSURANCE CARD(S) AT TIME OF SERVICE
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.