Fax (719) 546-0039
Fill out, print at home, bring to ITR and sign.
Print Blank Form
Consent for Treatment
I, the undersigned, do hereby agree and give my consent for the Institute for Total Rehabilitation, LLC, aka, ITR Physical Therapy, to furnish medical care and treatments to (individual receiving care) considered necessary and proper in diagnosing or treating his/her physical and/or injury condition.
Patient/Guardian Initial: _______
ITR personnel are authorized to leave message(s) at HOME on answering machine or with anyone who answers the phone and/or to contact patient at WORK about appointments on the account with ITR. Yes No
ITR personnel are authorized to call or fax patient data to Referring/Treating Physician, PCP, and/or Physician’s Assistant. Yes No
ITR personnel are authorized to communicate to insurance company and/or its representatives including insurance adjustors and case managers about patient account or medical information that would assist decision making processes. Yes No
Cancellation and No-show Policy
If you are unable to attend your scheduled appointment, YOU MUST NOTIFY ITR, WITHIN 24 HOURS to reschedule. Failure to attend your session without notice WILL result in a $25.00 charge for each missed appointment (patient is responsible for payment regardless of insurance coverage) and due at next scheduled appointment. Failure to keep the appointments recommended by your physician will be reported to the appropriate parties in writing.
Please know that this policy was established because we care about your recovery and the Quality of your Care.
I acknowledge and understand this policy:
Marketing & Promotions Release
I consent to having my photograph taken for the purpose of publications, research, promotion, and/or Brochure development. This informaiton and photograph will and may be used to educate providers and consumers of the services offered at ITR Physical Therapy.
I consent to my name and photograph published on the ITR website and/or Facebook pages.
By initialing, I acknowledge and approve of my photo and or name to used for the above said purposes.
HIPPA Privacy Practices
In signing this form, I acknowledge that I have reviewed the Notice of Privacy in its entirety and have had my questions answered thoroughly and to my satisfaction. I consent to the release of my protected health information for the purpose described in the Notice of Privacy Practices.
(X) _________________________________ Date:
Printed Name Signature
Staff Signature/Witness ___________________________________ Date: ____________________
Fax (719) 546-0039
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