Patient Authorization Record
Authorization for Treatment
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➢ I hereby give authorization for the performance of such rehabilitation procedures as permitted by Maryland Statutes under the appropriate scope of practice are, in the judgment of my physical therapist, deemed necessary. (see separate sheet for details of treatment procedures)
I hereby give authorization for the performance of such rehabilitation procedures as permitted by Maryland Statutes under the appropriate scope of practice are, in the judgment of my physical therapist including TELEHEALTH/eVisits (online video visits) using a HIPAA compliant platform whenever deemed necessary.
Authorization for Release of Information
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➢ I agree that AAA Physical Therapy, LLC may provide information from my medical record to persons involved in my medical care.
➢ I authorize the release of medical information necessary to obtain payment of any benefits available to me to AAA Physical Therapy, LLC for services rendered.
➢ I agree that AAA Physical Therapy, LLC may obtain information from others who have provided medical care to me and/or are responsible for the payment of all or part of my bills when this information is needed in order to treat, bill, and/or receive payment.
➢ I have read “Notice of Privacy Practices” mandated by HIPAA.
Authorization for Release of Payment
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➢ I authorize that direct payment of any benefits available to me be released to AAA Physical Therapy, LLC for services rendered.
Patient Agreement
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➢ I agree to pay AAA Physical Therapy, LLC charges for services rendered to me during my course of treatment.
➢ I agree to pay those charges, which may not be paid by my health insurance and are my responsibility per my insurance benefit. If I do not pay for charges that are my responsibility, I agree to pay AAA Physical Therapy, LLC collections costs including attorney and court fees.
Medicare, Medicaid, and Similar Benefits
➢ I agree that the information given to AAA Physical Therapy, LLC in applying for benefits under Medicare and Medicaid services are complete and accurate. I agree that AAA Physical Therapy, LLC may give Social Security Administration or its fiscal intermediary’s information necessary to process claims.
Workers Compensation
➢ I agree that the information given to AAA Physical Therapy, LLC in applying for benefits under Workers Compensation is complete and accurate. I agree that AAA Physical Therapy, LLC may give intermediary’s information necessary to process claims.
Do we have permission to send/leave appointment reminders, billing and information about your physical therapy on your answering machine/voice mail/email/text? I understand I may be charged for such calls by my wireless carrier and that such calls may be generated by an automated dialing system.
YES
NO
Please add your comments or conditions you would like us know:
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Patient Name
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First Name
Last Name
Patient Signature
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Witness Signature
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Signature of Legal Representative/POA
Submit
p. 443.979.7171
AAA Physical Therapy, LLC
admin@AAAPhysicalTherapy.com
8975 Guilford Rd Ste 170 Columbia, MD 21046
f. 667.200.5908
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