Acknowledgment of Practice’s Notice of Privacy Practices:
I acknowledge that I was provided a copy of the Notice of Privacy Practices (NPP) and that I have read (or had the opportunity to read if I so chose) and understand the Notice of Privacy Practices (NPP) and agree to its terms. To file a complaint with Texas
Medical Board call 1-800-201-9353.
I hereby authorize Loredo Hand Care Institute to furnish any medical records and/or other necessary information needed to process an insurance claim.
ASSIGNMENT OF BENEFITS
I, the undersigned, am the financially responsible party for the patient named above and agree to pay, in full, Loredo Hand Care Institute, for services rendered.
I accept Loredo Hand Care Institute fees as reasonable and customary.
Should your insurance deny payment for any and all services you are responsible for the amount billed.
NON-WORKMAN’S COMP DECLARATION
PLEASE READ - THE PHYSICIAN IS UNABLE TO DETERMINE WHETHER OR NOT THE SYMPTOMS YOU ARE SUFFERING ARE WORK-RELATED.
By signing below, you declare that you do not have a compensable work injury covered under a workman’s comp claim at this time. It is your responsibility as the patient to notify our office if you file a work compclaim. You also understand that should your workman’s comp claim be denied, you will be responsible for all balances in full. If group health insurance is available, we must receive a copy for processing as soon as you are aware the claim has been denied. This is not a guarantee that we accept your group insurance.
X-Ray & Ultrasound
I authorized Loredo Hand Care Institute to take x-rays and perform an ultrasound for my condition. I understand my x-rays and ultrasound and other pertinent information related to my treatment will be presented for analysis. I further understand this information is valuable in order to assist my doctor in his evaluation of an initial treatment plan, as well as modification to this plan during the course of treatment.