“We vow to honor, serve and protect our Veterans”

www.vwcalabama.com | 5911 Monticello Dr., Montgomery, AL 36117

Phone: 334-676-2797 | Fax: 334-323-7148

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Please complete all pages of this packet before submission.

 

 

 

***Veterans are exempt from $25 no-show fee. Non-veterans/self-pay agree to a $25 fee and separate financial agreement.

  

 

Please complete all pages of this packet before submission.

 

 

 

 

Please complete all pages of this packet before submission.

 

 

 

 

Please complete all pages of this packet before submission.

 

 

 

 

Please complete all pages of this packet before submission.

Consent to Evaluation and Treatment
I hereby consent to receive medical evaluation, diagnostic procedures, and treatment from the licensed healthcare providers, clinical staff, and allied professionals at Veterans Wellness Center of Alabama (VWC). I understand that treatment may include medical management, physical therapy, wellness services, or telehealth consultations, as deemed appropriate by my provider

I acknowledge that medicine and therapy are not exact sciences and that no guarantees have been made as to the results of any diagnosis or treatment. I understand that my provider will explain the nature, purpose, and expected benefits of recommended care, along with potential risks and alternative options, and that I have the right to ask questions at any time.

Right to Refuse or Withdraw Consent
I understand that I may refuse any specific treatment or withdraw my consent at any time. Refusal of treatment may affect my care plan or outcomes, which will be explained to me by my provider.

Financial and Insurance Responsibility
I acknowledge that I am responsible for any co-payments, deductibles, or non-covered services as determined by my insurance or funding source. I agree to inform VWC promptly of any changes in my insurance, contact information, or medical status.

Behavioral and Zero-Tolerance Policy
Veterans Wellness Center of Alabama is committed to maintaining a safe, respectful, and professional environment for all patients and staff. Harassment, threats, verbal abuse, discriminatory remarks, or physical aggression of any kind toward staff or other patients will not be tolerated.

VWC reserves the right to terminate services and dismiss a patient from care for any conduct that is disruptive, abusive, threatening, or compromises the safety and integrity of the clinical environment. Law enforcement may be contacted if necessary to protect staff or patients.

Acknowledgment
By signing below, I confirm that I have read and understand the above information, have had an opportunity to ask questions, and voluntarily consent to treatment and agree to abide by all clinic policies.

 

 

 

 

 

Please complete all pages of this packet before submission.

Notice of Privacy Practices
I acknowledge that I have received, read, or been offered a copy of the Veterans Wellness Center of Alabama (VWC) Notice of Privacy Practices. This document explains how my medical information may be used or disclosed by VWC for purposes of treatment, payment, and healthcare operations, as well as my rights under the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

Use and Disclosure of Information
I understand that my personal health information (PHI) may be used or disclosed for the following purposes:

• To provide, coordinate, or manage my healthcare and related services.
• To obtain payment for healthcare services rendered.
• For healthcare operations including quality assurance, training, and audits.
• When required by law, such as in cases of abuse, public health concerns, or court orders

I further understand that VWC will obtain my written authorization before using or disclosing my information for any purpose not permitted or required by law.

Authorization to Release Information
I authorize Veterans Wellness Center of Alabama to release my medical information to physicians, hospitals, laboratories, insurance companies, or other authorized individuals or organizations as necessary for the continuation of my care and for processing of medical claims. I also understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance
on it.

Patient Rights Under HIPAA
I understand that under HIPAA, I have the right to:

• Request restrictions on certain uses and disclosures of my health information.
• Inspect and obtain copies of my medical records. 
• Request an amendment to my medical records if I believe information is incorrect or incomplete.
• Request a list of certain disclosures made of my health information.
• File a complaint if I believe my privacy rights have been violated, without fear of retaliation.

Confidentiality Commitment
Veterans Wellness Center of Alabama is committed to maintaining the confidentiality of my medical information. All staff, contractors, and affiliates are trained and bound by law and policy to protect patient privacy and ensure compliance with HIPAA standards.

Acknowledgment of Understanding
By signing below, I acknowledge that I have read and understand the information above, have received or been offered a copy of the Notice of Privacy Practices, and understand my rights regarding the privacy of my protected health information.

 

 

 

 

 

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Telehealth Consent: I consent to receive care through telehealth if I qualify, understanding privacy limitations.

 

Student/Intern Participation: I understand that medical interns or students may observe or assist under supervision.

Image/Media Release: I consent to the use of photos, videos, or recordings for medical
documentation, education, or marketing.

Care Management: I consent to participate in coordinated care and case management services as part of my treatment plan.

 

 

 

 

 

 

Please complete all pages of this packet before submission.

Patient Informed Consent Form

For patients receiving TeslaMAX® Electrical Muscle Stimulation treatment administered at Veterans Wellness Center of Alabama.

I, the person signing this consent form below, acknowledge that I have been informed that the TeslaMAX® TM4 Electrical Muscle Stimulation device I am to be treated with in-clinic or being provided to me for my home use as part of my plan of care ordered by my health care provider, has not yet been cleared by the FDA for marketing in the United States of America. I have been informed that the TeslaMAX® TM4 Electrical Muscle Stimulation device is a “Work in Progress” and has not yet been granted an FDA clearance for marketing in the United States.

I understand that Rehaba will only allow the TeslaMAX® TM4 to be used on patients either in-clinic or for home treatment who have signed this form and are participating in a treatment plan of care like the one ordered by my health care provider.

The TM4 made available for my home use and/or treatment in-clinic is provided on loan by Rehaba, Inc., 38954 Proctor Blvd., #138, Sandy, OR 97055, telephone number 702-871-3200. Should I be allowed to take the
TeslaMAX® TM4 device home with me, I agree to return the device upon demand.

I agree that I have not been promised any type of guaranteed result, benefit, or outcome resulting from my use of or treatment by said “Work in Progress” TeslaMAX® TM4 device.

Summary:

Patient agrees that the use of the loaned “Work in Progress” FIELD BETA TEST TeslaMAX® TM4 unit is optional and not required and done at the patient’s own risk. Patient acknowledges that, unlike Rehaba’s other electrical stim devices (such as the TeslaMAX® TIER4 unit) which are cleared by the FDA as safe and effective, the TeslaMAX® TM4 unit is not yet cleared for marketing by the FDA and has not yet been found to be safe and effective.

 

MY SIGNATURE BELOW SIGNIFIES THAT I HAVE READ, UNDERSTAND, AND AGREE TO ALL OF THE TERMS REGARDING MY RECEIPT OF TREATMENT. THE TREATMENT IS AS STATED ABOVE AND I AGREE TO “HOLD HARMLESS” BOTH REHABA, INC. AND THE HEALTH CARE PROVIDER AT VETERANS WELLNESS CENTER OF ALABAMA WHO HAS PRESCRIBED HOME OR IN-CLINIC ELECTRICAL STIMULATION FOR ME. I WILLINGLY AND KNOWINGLY AGREE TO PARTICIPATE IN THE FIELD BETA TEST OF SAID “WORK IN PROGRESS” TM4 ELECTRICAL MUSCLE STIMULATION DEVICE TEST FOR REHABA, INC.

 

 

Administered under Veterans Wellness Center of Alabama
Rehaba, Inc. 38954 Proctor Blvd., #138, Sandy, OR 97055 | (702) 871-3200 | regen@rehabainc.coM

 

 

 

 

Please complete all pages of this packet before submission.