POLICIES FORM

General Consent for Treatment

At Maranatha Physical Medicine & Rehabilitation, PLLC we look forward to treating you as a patient. However, we need your permission for our physician(s)/practitioners to examine you, provide treatments, and provide diagnostic studies as necessary. If more invasive procedures are deemed necessary, the risks and benefits of those invasive treatments will be explained to you. I give general consent to be treated by Lisa Barrett, MD.

Privacy Policy

New federal regulations require physician practices like Maranatha Physical Medicine & Rehabilitation, PLLC to keep your medical information private. Our practice has always guarded the privacy of our patients. We only share your medical information with other healthcare providers that are participating in your care, your insurance company to provide your benefits, or for medical management issues. If anyone else helps us with our internal operations, we will require them to keep any patient information they may see confidential. All other releases of information have to be specifically authorized by you. If you ask us to account for these release of information, we will provide that to you. You may also request and receive a copy of your medical record and ask questions about its content. We will keep your record as long as you are a patient of the practice and seven years after your last visit. You will be given a form to sign which shows the details of to whom you wish to have your PHI (Protected Health Information) released.

I acknowledge that I have been informed about the privacy of my medical record.

Maranatha Physical Medicine & Rehabilitation, PLLC Financial Policy/Assignment of Benefits

As a courtesy to our patients, Maranatha Physical Medicine & Rehabilitation, PLLC will accept assignment for some commercial insurance programs and Medicare. We will file your primary insurance claim for you. Once the primary insurance has paid, we will also file your secondary insurance, if you have provided us with that information. However, insurance is a contract between you and your insurance company. Therefore, we ask that you acknowledge your responsibility for the payment for any services rendered by our practice. If the insurance denies coverage, disallows a service, or otherwise does not pay the clam, you are still responsible for the fees. In addition, if the fees for our services are not paid, we may turn the account over to a collection agency. If an account is turned over for collection, their fees, attorney's fees, and court costs will be added to the account balance. Also, your insurance company may ask us to provide information concerning your treatment before they will pay for the services.

I acknowledge responsibility for payment of fees for services provided by Maranatha Physical Medicine & Rehabilitation, PLLC and the providers within the practice and I authorize the practice to release any medical information, if necessary, to my insurance company.

I consent to all checked checkboxes on this form.

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