Dreher Physical Therapy
Physical Therapy, Personal Training and Massage
Orthopedics, Geriatrics, Neurology and Rheumatology
Admission and Release of Information (HIPAA)
hereby consent to treatment by Dreher Physical Therapy. I also grant permission to release information about me and/or discuss issues of my care to any persons relevant, including:
I understand the need for courtesy to give my therapist at least 2 business days notice if I need to cancel my appointment and agree to pay a $25 cancellation fee if I fail to give sufficient notice. A 'no-show' may result in termination of therapy
I understand Medicare will pay 80% of charges and my secondary insurance will be billed the remaining 20%, but I assume responsibility for any co-pay. If I have Blue Cross, Harvard Pilgrim, etc., I agree to pay the co-pay and/or deductible. My co-pay will be collected on the day of appointment.
If my insurance denies payment, I understand that I am responsible for payment of services.
When privately paying and requesting services not covered by insurance, I understand that my insurance will not be billed and that I am responsible for a private pay rate of $100 per visit, payable upon receipt of billing statement.
I have read and understand my rights as a patient (see opposite side of this page).
Thank you for submitting the HIPPA release form.
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