Consent to Treat & Conditions of Admission

1. CONSENT TO REHABILITATION PROCEDURES: The undersigned consents to the procedures which may be performed during this and future out-patient physical therapy and occupational therapy visits that are performed at Buffalo Rehab Group Physical Therapy and Occupational Therapy, PLLC (the Company). I/We consent to examination, therapy procedures and therapy care given to the patient by or under the supervision of the physical therapist (PT) and occupational therapist (OT).

2. LEGAL RELATIONSHIP BETWEEN BUFFALO REHAB GROUP AND EMPLOYEES: All PTs, Physical Therapist Assistants (PTA), OTs, and Occupational Therapist Assistants (COTA) are employed by the Company. The Company serves as a medical teaching facility; therefore, PT / OT students and PTA / COTA students may be involved in your care under the supervision of an attending PT, OT, PTA or COTA.

3. NO SHOW / CANCEL POLICY: The undersigned agrees, whether he/she signs as agent or as a patient, that in consideration of the services to be rendered to the patient, he/she hereby acknowledges that if they no show or cancel or appointment within 24 hours for three consecutive times, they will be subject to discharge from care. A new referral and evaluation would need to be performed for continued care to occur.

4. ASSIGNMENT OF INSURANCE BENEFITS: The undersigned authorizes, whether he/she sign as agent or a patient, direct payment to the Company of any insurance or other applicable (e.g. Medicare, Commerical Insurance) benefits otherwise payable to or on behalf of the undersigned or patient for these outpatient services, at rate not to exceed the Company’s regular charges. It is agreed that payment to the Company, pursuant to the authorization, by an insurance company shall discharge said insurance company of any and all obligations under a policy to the extent of such payment. Any pre-certification of insurance benefits is the patient’s sole responsibility; however, the company will make every effort to get this information in advance of the first visit. The undersigned authorizes payment of Medicare/Insurance benefits to be made on behalf of the patient for all services furnished by the Company. It is further understood by the undersigned that he/she is financially responsible for charges not collected by this agreement, unless otherwise stated by applicable written contract or law.

5. PHOTOGRAPHING AND VIDEOTAPING: The Company may photograph, film, videotape, or otherwise make video and/or audio recordings of the patient only for the purposes of diagnosing and treating the patient’s condition. No photograph or videotape will be used for any other purposes other than treatment without the patient’s written consent.

6. DISCLOSURE OF HEALTH INFORMATION: I understand that the Company is a health provider who must comply with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA protects the privacy of individually identifiable health information. The Company Notice of Private Practice outlines your rights and responsibilities regarding your medical information and who to contact if you have any concerns regarding your medical information. Your initials below acknowledge that you have been given a copy of the Company’s Notice of Privacy Practices.