GENERAL CONSENT

I request and authorize the rehabilitation services as my physicians (his/her assistants or designees collectively called "the physicians") advise. I understand that in emergencies it may be advisable to expand or deviate from the services listed here in order to preserve my life or health. I consent to these expanded services and procedures. I understand that Agency personnel will provide services for me according to the physicians' instructions.

I authorize the Agency to release any and all information from my medical record, including but not limited to plan of care, visit notes, special test results, medical history forms, etc.

I authorize the Agency to release any and all information to:

1. Any third party payer or insurance company (for example Medicare, Medicaid, Blue Cross/Blue Shield, commercial health insurers, automobile no-fault insurers, workers' disability compensation insurers, health maintenance organizations, preferred provider organizations, and managed care plans) which are responsible in whole or in part for paying my health care bill so that the Agency may be paid for its services;
2. Any health care facility or physician to which I am referred or transferred for continuity of care.
3. Any independent auditors or reviewers retained by the Agency, or by any third party payer or insurance company so that these reviewers can analyze quality, utilization and/or charges.
4. My current or potential employer, if the purpose of the medical examination and/or treatment arises from or pertains to my current or prospective employment, e.g., an employment, physical or care and treatment arising from a workplace injury.
5. Any related facility, entity or physician.

I acknowledge that a copy of the Rivetus Rehabilitation Privacy Practices Notice (HIPAA) dated 01/01/2021 has been provided to me.

Rivetus Rehabilitation will make every effort to verify insurance coverage, however this information is only an estimate. It is ultimately your responsibility, and while we make every effort to verify your out-of-pocket costs, we recommend you contact your insurance company for expected cost of services.