Bootcamp Clone of CRA Business Consent Authorization

CONSENT FOR TREATMENT:

I authorize Cornerstone Therapy Services to perform the therapy(s) described below.

I have been informed of the reason(s) for therapy(s), along with the expected benefits.

Please check all that apply:

Speech TherapyOccupational TherapyPhysical Therapy

Telehealth:

Speech TherapyOccupational TherapyPhysical Therapy

The therapy(s) was explained to me in detall and all my questions were fully answered. Understanding this, I authorize Cornerstone Therapy Services consent to treat : First Name Last Name

I also certify that no guarantee or assurance has been made as to the results that may be obtained.

RELEASE OF MEDICAL RECORD:
To ensure proper follow-up and continulty of care, I agree that a copy of the medical record may be released to my physician, and designated referral physician and/or the provider who referred me. I authorize Cornerstone Therapy Services to release the medical records of First Name Last Name as explained above.

INSURANCE AUTHORIZATION:

I request that payment of authorized benefits be made to Cornerstone Therapy Services on my behalf, for any services provided to me. I authorize any holder of medical and other information about me to release to Medicaid and its agents, any insurance company, any other third-party payer, state medical assistance agency
or any other governmental or private payer responsible for paying such benefits, any information needed to determine these benefits or benefits for related services. I agree to pay all charges not covered by a third party payer. I authorize a copy of this authorization to be used in place of the original. I understand that filing
insurance is a courtesy and not an obligation. I also understand that the contract Is between myself and the insurance carrier, not the practice and the insurance carrier.

Name

First NameLast Name

Signature

Date Signed

Date

Consent Authorization Form