Provider Name: Mobile Rehab 

Office address: 229 Fearrington Post, Pittsboro, NC 

I consent and authorize Mobile Rehab to provide physical therapy services. 

 

Release of Information 

• This authorization, or copy of same, authorizes the release to Mobile Rehab of any medical information necessary for treatment and/ or process claims for services rendered by Mobile Rehab. 
• This authorization authorizes Mobile Rehab to disclose any information furnished Mobile Rehab, or obtained by Mobile Rehab in connection with patient’s treatment (including information concerning a related Medicare claim), to any physician, governmental agency (including the Social Security Administration or any of its intermediaries or carriers), insurance company or health care facility requesting such information. 
• Patient and authorized Patient Representative agree to execute any documents and perform any acts that Mobile Rehab may reasonably request with regards to therapy services. 
• Patient and authorized Patient Representative acknowledges receipt of Mobile Rehab’s Notice of Privacy Practices. 
• The undersigned warrants and represents that attached hereto are originals or certified copies of any applicable powers of attorney, health care surrogate forms or court orders appointing the undersigned as the legal guardian of Patient. 

Reimbursement Coverage 

• Patient or authorized Patient Representative hereby assigns to Mobile Rehab all private medical insurance benefits (primary and secondary, including med.gap providers) or other benefits to which Patient may be entitled for any therapy services rendered by Mobile Rehab.
• Patient or authorized Patient Representative authorizes and directs Mobile Rehab to apply and file for all such benefits on behalf of Patient. 
• Patient or authorized Patient Representative agrees that he/she shall be jointly and severally financially responsible for any portion of Mobile Rehab’s invoice that is not paid, including but not limited to (i) any applicable deductibles or co-insurance, (ii) any non-insured or non-covered services authorized.
• Patient or authorized Patient Representative authorizes Mobile Rehab to represent Patient during the appeals process in the event of a denial of Medicare benefits.

Term 

This patient consent and authorization given to Mobile Rehab as set forth above will remain in full force and effect until terminated in writing by patient or authorized patient representative.