I consent to the provision of care rendered by the therapists of Innovative Therapy & Wellness. I authorize Innovative Therapy & Wellness and any therapist who treats me, the patient, to release to it's authorized billing agents or billing agents of any of the third party payer, or any other intermediaries responsible for payment of charges, diagnosis and other necessary medical information via fax or other methods. I authorize provision of information concerning my care, condition, and treatment for quality assurance and risk management purposes.
I hereby authorize Innovative Therapy & Wellness to release any medical information necessary to process my insurance claim. I understand verification of insurance benefits is provided as a courtesy and insurances will not guarantee medical benefits or payment for services. This information is given as a guideline of what my insurance may reimburse and I am strongly encouraged to contact my insurance company directly in order to understand my plan's coverage and limitations. I understand I am ultimately responsible for all charges for services provided to me.
The information I have given on this form is true and accurate to the best of my knowledge. I have read and fully understand Innovative Therapy & Wellness' Notice of Privacy Practices. I understand Innovative Therapy & Wellness may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of services provided, and any administrative operations related to treatment or payment. I understand I hav the right to restrict how my personal health information is used and disclosed for treatment, payment, and administrative operations if I notify the practice. I also understand Innovative Therapy & Wellness will consider the request for restrictions on a case by case basis, but does not agree to request for restrictions.
I hereby consent tot he use and disclosure of may personal healthi nformation for purpose as noted in Innovative Therapy & Wellness' Notice of Privacy Practices, I understand I retain the right to revoke this consent by notifying the practice in writing at any time.