Consent & Agreement Form "*" indicates required fields Step 1 of 3 33% Section 1: Consent for ServicesPlease review and fill out the information below to provide consent for services.Name*(Enter your name to consent to services.) First Last I, ____________________, consent to receive services from Active In-Home Therapy. Privacy Notice The information collected is private and will not be shared unless directly related to your care. Authorization to Release Medical Information* I authorize Active In-Home Therapy Inc. to obtain or release all medical and related information to facilitate the provision and continuity of my healthcare. I authorize Active In-Home Therapy Inc. to consult with my physicians, my family, and any persons or agencies that provide healthcare services to me. Physician NamePhysician Phone NumberFinancial Agreement* I agree to accept full financial responsibility in accordance with Active In-Home Therapy rates and terms. I agree to pay any collection expenses and/or attorney fees if the account is forwarded to a collection agency due to delinquency and/or non-payment. I understand that there will be a 10% charge for non-payment after 30 days from the invoice date. Medicare Agreement I understand that it is my responsibility to investigate whether I am eligible for Medicare services. I hereby agree that by entering into this agreement with Active In-Home Therapy, I am indemnifying them against any future determination that I am/was eligible for Medicare during the time of Active In-Home Therapy services. I also agree that Active In-Home Therapy discussed my possible eligibility for Medicare services before entering into this agreement.Medicare Agreement* I understand and agree to the Medicare-related statements. Client Signature*Sign here to certify understanding of and agreement with the above statements and information.Date* Month Day Year Section 2: Fee SchedulePhysical Therapy Occupational Therapy Speech Therapy Social Work Registered Nurse Massage Therapy Fees for the above services: Evaluation (1 hour) $260 Follow-up Visits (per hour) $240 Other Services: – PTA (Physical Therapy Assistant) Visits (per hour) $190 – COTA (Occupational Therapy Assistant) Visits (per hour) $190 – Home Safety Assessment (1 hour) $325 Terms: – All Therapy Visits are assumed to be one hour unless prior arrangements have been made with the office. – The “Therapy Hour” usually lasts 45-50 minutes. – Invoices will be sent out every 2 weeks. – Payment is due upon receipt of invoices. – Cancellations without a 24-hour notice will be charged a cancellation fee of 50% of the regular visit charge. – Visits will be discontinued with accounts exceeding 30 days past due. A surcharge of 10% will be billed on accounts 30 days overdue. – Services provided on a private pay basis. Insurance is not accepted. Client Acknowledgment: I, ________________________________________, certify full understanding and am in agre Name* First Last Client Signature*Sign here to certify understanding of and agreement with the above statements and information. Section 3: Advance Beneficiary Notice of Noncoverage (ABN)Patient Name* First Last ACKNOWLEDGEMENT:* I acknowledge that I want the skilled services provided by Active In-Home Therapy, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. Additional InformationThis notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy.Client Signature*(Please sign to acknowledge understanding and agreement).CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
