Patient Agreement. The Patient Agreement is available at any time on the ETC website located at: xxxx://xxxxxxxxxxx-xxxxxxx-xxxxxx.xxx I may also obtain a copy from my ETC therapist upon request, or by ETC, or may access a copy for review in the ETC waiting room. The Patient Agreement includes explanations of the following: Consent for Treatment Notice of Privacy Practices Financial Policy General Office Policies “I (Guardian, if patient is a minor) have read in full, have been provided adequate opportunity to clarify any questions, understand, and agree to the Empowerment Therapy Center’s Patient Agreement. I also understand that the Patient Agreement may be modified without notice. I will discuss these policies with my (or the child’s) therapist, and I understand that I may ask questions about them at any time in the future. I consent to accept these policies as a condition of receiving mental health services.” Patient/ (or guardian if minor) Signature: Patient Name: Guardian (if minor) Name: Witness Signature: Date: Patient DOB: Phone: (833) ETC-LIFE Email: xxxx@xxxxxxxxxxxxxxx.xxx 0000 Xxxxxxx Xx, Xxxxx 000 Manassas, VA 20110 RELEASE OF MEDICAL INFORMATION Date of Release Dear Dr. (Primary Care Physician), We are currently working with your patient, , (DOB: ) in outpatient mental health counseling. Many insurance carriers require that health information on clients must be obtained. In order to fulfill this requirement, we must request that you either mail or fax the client’s latest physical health information. Our mailing address is: Empowerment Therapy Center, etc, PLLC 0000 Xxxxxxx Xx, Xxxxx 000 Manassas, VA 20110 Our fax number is: 000-000-0000 Thank you for your prompt attention and your cooperation in this matter. Below you will find the signatures of the client/ guardian indicating agreement with this release. Signature of Client/Guardian Date Signature of Staff Witnessing Date Date Sent to PCP: Clinician: Please complete this form and either fax or mail a copy of this form to the above- mentioned doctor. Scan this completed form with the date sent in the client’s chart. Phone: (833) ETC-LIFE Email: xxxx@xxxxxxxxxxxxxxx.xxx 0000 Xxxxxxx Xx, Xxxxx 000 Manassas, VA 20110 GENERAL RELEASE OF INFORMATION CLIENT NAME: DOB Date of Release: I hereby give my written permission for Empowerment Therapy Center, etc to exchange the following verbal or written information as indicated with: (Name or Entity). Extent or nature of use/disclosure is limited to: (Check or list all th...
Patient Agreement. The information overleaf has been explained to me and I understand that treatment with GLP1 agonist will be stopped and alternative options considered if the beneficial effects on my weight and HbA1c are not achieved after 6 months or continued long-term.
Patient Agreement. ➢ I acknowledge and understand the above information. ➢ If I experience any of the following I will contact Master Eye Associates or another eye care professional immediately: irritated eyes, red eyes, discharge or watery eyes; worsening pain in or around my eyes even after contact lens removal; sudden blurry vision or light sensitivity. ➢ If I sleep while wearing my contact lenses, I have advised my optometrist and I will return for a follow-up exam in 6 months. ➢ I understand that failure to follow prescribed wearing guidelines and proper lens care could result in injury to my eyes. ➢ ❑ EXPERIENCED WEARER - I acknowledge that I am an experienced contact lens wearer and I do not need instruction in contact lens care or insertion and removal of my contact lenses. ➢ ❑ NEW CL WEARER - I have been instructed in the care of my contacts and understand that failure to follow all instructions may result in discomfort or blurred vision and could result in injury to my eyes. I understand that contacts are fragile and that there is no warranty against damage to my contact lenses. I have been instructed, and have practiced, insertion and removal of my contact lenses and I am ready to begin wear on my own. ➢ I acknowledge that I have received a copy of my contact lens prescription.
Patient Agreement. I acknowledge that there are proper methods of insertion and removal, and use and care of contact lenses. I understand there are associated risks with over wearing and improper use of contact lenses. I understand that if I should experience sudden or prolonged redness or irritation, I should call this office immediately. I understand that noncompliance may result in unsatisfactory service from contact lenses, and could result in injury to my eyes. I understand that follow up care is of optimum importance. I am required to complete the follow up care specified by my eye care physician prior to having my lens prescription finalized and released. And furthermore, I am aware of the importance of annual exams while wearing contact lenses. Patient Name: Date: Print
Patient Agreement. The information a bo ve has been explained to me and I understand that treatment with G L P 1 A go n i s t will be stopped and alternative options considered if the beneficial effects on my weight and HbA1c are not achieved after 6 months, or continued long-term.
Patient Agreement. The information overleaf has been explained to me and I understand that treatment with: (Insert name of medicine) will be stopped and alternative options considered if the beneficial effects on my weight and HbA1c are not achieved after 6 months, or continued long-term. Today 6 month’s target Weight (3% loss needed by 6 months) HbA1c (11mmol/mol (1%) reduction needed by 6 months) eGFR (to check your kidney function) To be measured in 6 months Patient name ……………………………………………………………………. Patient signature ………………………………………………………………… Clinician name ……………………………………………………………………
Patient Agreement. M OBILE PHONES I agree to switch off my phone before entering the building, and keep it turned off whilst in the building. REPEAT PRESCRIPTIONS I agree to request my medication 2 working days before I require it. I also agree to make my request either in person, post, online or on a slip provided. Please note we do not take requests over the telephone. A PPOINTMENTS I agree to attend my appointment on time. I acknowledge that if I arrive late for my appointment, I may be asked to re-book. If you have more than one problem you wish to discuss please ask the receptionist for a double appointment. When booking an appointment reception staff will ask for a reason. All staff have signed a confidentiality agreement. EMERGENCY APPOINTMENTS I agree to use these appointments for medical emergencies only. These are NOT to be used to request medication or fit notes. FIT NOTES Fit notes are at the discretion of the clinician.
Patient Agreement. The undersigned applies for financial assistance indicated in this application and represents that all statements made in this application are true and are made for the purpose of obtaining financial assistance. The original or a copy of this application will be retained by the creditor, even if financial assistance is not granted. The undersigned also agrees to allow this facility to contact any or all of the above references for credit verification, including credit bureaus. Patient Signature Responsible Party or Spouse Signature Facility Representative Department Date Date: Patient Name: Account Number: Admission Date: Discharge Date: Estimated Insurance Liability $ Account Balance: $ Total Amount Due $ Dear : Attached you will find a financial assistance application form. Financial assistance is based on current balances. If you qualify for any financial assistance, payments already made to this account will not be refunded. Please fill out the application completely and provide me with the following indicated support documents within two (2) weeks: Last year’s federal tax return with W-2, W-2G, or 1099-R forms and support schedules. Proof of income (i.e., check stubs, Social Security Benefits, etc.). Bank statements for the past three (3) months. The financial statement must be signed by the guarantor and the guarantor’s spouse, if applicable. Thank you for your anticipated cooperation in gathering the information needed for the application. Please be aware that if all information is not received, your application for assistance will not be processed. Your account will be kept open for two (2) weeks pending the return of the above information. If you have any questions, please call toll-free at (000) 000-0000, ext. 2718, Monday through Friday, 8:30 a.m. to 4:30 p.m. Sincerely, Xxxx Xxxxxxxx Director, Patient Accounts Enclosures Date: Patient Name: Account Number: Dates of Service: Your application for financial assistance has been approved in the amount of %. This allowance will be applied to Texas Rehabilitation Hospital of Arlington charges remaining after all applicable insurance benefits have been paid. This allowance does not apply to your physician’s bill or non-covered items such as private room, take home items, etc. The balance remaining, after financial assistance has been applied, must be paid by cash, personal check or money order. Please contact the Patient Accounts Department regarding your choice of payment options. Your current balance...
Patient Agreement a. Patient agrees that he or she will NOT submit a xxxx to a Medicare Carrier for treatment by Physician during the period of time in which Physician has elected to opt out of the Medicare Part B Reimbursement system, even though such treatment may be otherwise covered by Medicare.
Patient Agreement. The Patient Agreement is available at any time on the ETC website located at: xxxx://xxxxxxxxxxx-xxxxxxx-xxxxxx.xxx I may also obtain a copy from my ETC therapist upon request, or by ETC, or may access a copy for review in the ETC waiting room. The Patient Agreement includes explanations of the following: Consent for Treatment Notice of Privacy Practices Financial Policy General Office Policies “I (Guardian, if patient is a minor) have read in full, have been provided adequate opportunity to clarify any questions, understand, and agree to the Empowerment Therapy Center’s Patient Agreement. I also understand that the Patient Agreement may be modified without notice. I will discuss these policies with my (or the child’s) therapist, and I understand that I may ask questions about them at any time in the future. I consent to accept these policies as a condition of receiving mental health services.” Patient/ (or guardian if minor) Signature: Patient Name: _____________________________ Guardian (if minor) Name: ___________________________________
