Patient Consent for Treatment and Financial Responsibility:
- I consent for the above individual to receive therapy services by the T&LC.
- I consent to the release of all medical records to the referring and family
physicians and to my insurance company, if applicable. I allow fax transmittal of medical records if necessary.
- I agree that I will promptly notify T&LC of any changes in the above information.
- I authorize the insurance companies listed above; TennCare, Medicaid and/or Medicare, if applicable, to make payments directly to T&LC for any covered services provided.
- I agree to be financially responsible for payment. Although insurance may be assigned to and directly payable to T&LC, I understand that any part of the account not paid by insurance is owing and payable.
- I understand that I am financially responsible for any deductible, co-pay or services not covered by insurance.
- Required services, billable through the Department of Mental Retardation
Services, that are specified on an Individual Support Plan are provided at no to the families.
- I consent to the release of any medical information necessary to process medical claims and request payment of medical benefits to T&LC for services rendered.
- I understand that accounts past due may be turned over to a collections agency.
- I have read and fully understand the above consent for treatment and financial responsibility.