Benefit Assignment/release Of Information

I, hereby assign all medical and/or rehabilitation benefits to include major medical benefits to which I am entitled, including Medicare, Medicaid, private insurance and third-party payers to The Institute for Total Rehabilitation, LLC. A photocopy of this assignment is to be considered as valid as the original. I, hereby authorize said assignee to release all information necessary, including Medical Records, to secure payment.

Financial Policy Statement

We bill your insurance carrier solely as a courtesy to you. You are responsible for the entire bill when the services are rendered. We require that arrangements for payment of your estimated share be made the day of service. If your insurance carrier does not remit payment within 60 days, the balance will be due in full from you. In the event that your insurance company requests a refund of payments made, you will be responsible for the amount of money refunded to your insurance company. In the event your company establishes an internal usual and customary fee schedule, you will be responsible for the difference remaining.

If any payment is made directly to you for service billed by us, you recognize an obligation to promptly remit said payment to The Institute for Total Rehabilitation, LLC.

The above does not apply for those patients that are considered Workers Compensation (W/C). However, be advised if you claim W/C benefits and are subsequently denied such benefits, you will be held responsible for the total amount of charges for service rendered to you.

I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees, and attorney fees.

Insurance Benefits:  Deductible: _________   Co Insurance: _________  Co Pay: _________

Arrangement for payment of patients share ______________________________________________________________________

______________________________________________________________________

Note:  Estimate coverage information is provided as a courtesy to our patients, but is not intended to release them from total responsibility for their account balances.

The above information has been read and explained to me. I understand the responsibility for the payment of my account.

I acknowledge and understand both the Release of Information and Financial Policy Statement:

(X)_________________________________________            _______________________________

Patient/Guardian/Responsible Party                                               Date

____________________________________________           _______________________________

Clinic Representative/Witness                                                        Date