TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses:
TREATMENT AGREEMENT. Welcome to my practice! This document (The Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPPA), the federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment and health care operations. HIPPA requires that I provide you with Notice of PRIVACY Practices (the Notice) for the use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is included with this Agreement, explains HIPPA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I provided you with this information at the start of treatment. Although these documents are long and sometimes complex, it is important that you read them carefully. You will also receive a copy of this information to keep. We can discuss any questions you have about them after you have read them. Please make sure to let me know if there is any part that you do not understand. When you sign this document, it will also represent an agreement in writing at any time. That revocation will be binding on me unless I have taken action concerning it, re: if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy or if you have not satisfied any financial obligations you have incurred.
TREATMENT AGREEMENT. I agree to accept the following treatment contract for buprenorphine office-based opioid addiction treatment:
TREATMENT AGREEMENT. I agree to accept the following treatment agreement for extended-release injectable naltrexone (XR-NTX) office-based opioid use disorder treatment:
TREATMENT AGREEMENT. Welcome to my practice. This Informed Consent Agreement (“Agreement”) contains important information about my professional services and business policies. It is also intended to inform you of state and federal laws and your rights. We can discuss any questions you have before you sign this document or at any time in the future. You may revoke this agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it or if you have not satisfied any financial obligations you have incurred.
TREATMENT AGREEMENT. The Supplier is responsible for entering into a Treatment Agreement with the Hospital department treating the patient. The Treatment Agreement shall contain details with regards to the treatment (ordering procedures, contact information and so forth). The Treatment Agreement shall be archived by both the Supplier and the Customer. The Supplier is responsible for providing a copy to the Contract Manager.
TREATMENT AGREEMENT promise full cooperation with my treating physician whether by surgical or non-surgical means. I understand that if I do not follow my doctor’s instructions concerning my care and treatment, including any necessary medications, the outcome of my care and treatment could be put into jeopardy and less than optimal results may occur.
TREATMENT AGREEMENT. I will make a copy of your insurance card at our first meeting, and will verify your benefits. If you would prefer to do the verification, that is fine as well. If you choose not to bill your insurance, or if I am not paneled with your insurance—we will provide you with a statement of services at each session. If I am given ample notice of illness, other circumstances—you will not be charged for a re-scheduled session. However, NO-SHOWS will be charged the regular rate.
TREATMENT AGREEMENT. As a participant in buprenorphine (Suboxone) treatment for opioid use disorder, I agree to the following:
TREATMENT AGREEMENT. If physical therapy is being sought due to an accident, please indicate the and of the accident Last Name First Name Middle Initial Home Address City State Zip Code Phone Numbers: Home: ( ) Work: ( ) Cell: ( ) Social Security Number: - - Date of Birth / / Emergency Contact Name and Phone Number(s) Name of Primary Insurance Company: Insured’s ID Number _ Group Number Plan Name and/or Plan ID Number: Cardholder Date of Birth / / Responsible Party’s Last Name First Name Middle Initial Relationship to Patient Home Address City State Zip Code Phone Numbers: Home: ( ) Work: ( ) Cell: ( ) Employer’s Name: Last Name First Name Office Address City State Zip Code Phone Number ( ) FINANCIAL RESPONSIBILITY: I hereby guarantee payment of therapy services to East and West Physical Therapy, LLC and acknowledge receipt of the fee schedule. I understand I am responsible for payment of my account and this facility does not accept responsibility for negotiating a settlement on a disputed claim. All balances, after maximum insurance payment has been received by the facility, are due and payable upon receipt following the last insurance monies received by the facility. Interest of 1.5 % monthly will be added to all accounts that become 30 days past due. In the event this account is placed with an attorney or collection agency for collection, the undersigned agrees to pay reasonable attorney’s fees, legal expenses and lawful collection costs in addition to all other sums due hereunder. X Initial
