The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly. I understand that I am financially responsible for any balance that is unpaid by my insurance company. I under- stand Physical Therapy will impose a late fee of $45 for any balance that is older than 120 days, unless I have prior payment arrangements. I further authorize Physical Therapy and my insurance company to release any information that is required to process my claims.
I hereby consent to treatment procedures and patient care which in the judgment of my therapist and/or physi- cian may be considered necessary or advisable while I am a patient of Physical Therapy.
I hereby authorize the use or disclosure of my individually identifiable health information as described in the NOTICE OF PRIVACY PRACTICES I received.