By signing below you are stating that you have authority to sign to the terms below for the person below.

The treatment that will be provided is NOT related to any third-party liability event (car accident, slip and fall, etc) that there is not a claim open, or claim under litigation.  If there is an open or under litigation claim, then I will need to provide the claim number, adjuster information, and any other pertinent information before beginning treatment.

By signing below, you hereby agree for the clinical staff of Evolution Rehab Group to render Physical, Occupational, or Speech therapy depending on your orders performed by one of our qualified licensed therapist or therapy assistants licensed in the state of Florida and in good standing (employee, contractor, or vendor).  You will have your medical care documented in our system and kept on record for the state mandated time frame (currently 7 years).  Consent will remain through successive treatment episodes. At the resumption of services any time after a discharge or at the onset of any changed episode, we will gather new consent at that time.   

ASSIGNMENT OF BENEFITS, ASSIGNMENTS OF RIGHTS TO PURSUE ERISA AND OTHER LEGAL CLAIMS ASSOCIATED WITH MY HEALTH INSURANCE PLAN (INCLUDING BREACH OF FIDUCIARY DUTY) AND DESIGNATION OF AUTHORIZED REPRESENTATIVE. I irrevocably assign and convey directly to the above-named provider, as my designated authorized representative, all insurance benefits, if any, otherwise payable to me for services rendered by provider, regardless of its managed care network participation status. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the above-named provider any and all Plan documents, summary benefits description, insurance policy, and/or settlement information upon written request from the above-named provider or their attorneys in order to claim such benefits. I also assign and/or convey to the above-named provider, as my designated authorized representative, any legal or administrative claim or chosen action arising under any group health plan, employee benefits plan, health insurance or tortfeasor insurance concerning expenses incurred as a result of services received from the provider. This includes an assignment of ERISA breach of fiduciary duty claims. I intend by this assignment and designation of authorized representative to convey to the above-named provider all my rights to claim (or place a lien on) the medical benefits related to the services provided by the above-named provider, including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims). The above-named provider or their representative is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) make statements about facts or law; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or actions against any liable party, insurance company, employee benefit plan, health care benefit plan, or plan administrator. The above-named provider, as my assignee and my designated authorized representative, may bring suit against any such health care benefit plan, employee benefit plan, plan administrator or insurance company in my name with derivative standing at provider’s expense. This assignment is valid for all administrative and judicial reviews under PPACA, ERISA, Medicare and applicable federal and state laws. Any amount of co-pay, co-insurance, deductible or any amount not covered because patient elected to be under a different plan after verification or under a home care episode and did not call to cancel services will be patient responsibility for services rendered paid in master rate full amount.  There are some insurance companies that pay the patient to then pay the provider. It is up to you to assign those checks or just deposit them and pay for the amount due. 

Federal law requires that we seek your acknowledgement of the Notice of Privacy Practices. I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years. I can view them online at www.evolution.rehab in the Patient section on the bottom of the page labeled privacy notice. ​

I understand that if I am under an active episode of Home Health (Nurse, Therapist, Aide provided by Medicare) even if no one is coming to the house right now, that I am not eligible for outpatient services, even if provided at my home.  It is ultimately my responsibility to acknowledge that I am not under an active episode of home care, and that all services have been officially discharged at least 1 calendar day prior to my first billable service otherwise I can be potentially liable for charges associated with my services performed by Evolution Rehab Group.  Furthermore if at any time I sign with a Medicare Certified Home Health Agency between now and when I am discharged from Evolution Rehab Group, I MUST stop treatment with Evolution Rehab Group, and let them know, or any session's financial obligations I have during this time can be transferred to me for payment.

All claims will be submitted on patient’s behalf through Evolution Rehab Group.  Please note we submit claims typically once a month.   Therefore, the date of claim and explanation of benefits and any notice of patient responsibility can be months after treatment.  All claims will reflect Evolution Rehab Group as the provider.  We do not collect money up front for insurance based cased. Any claims without our facility information are not from our organization.  Notices of patient fiduciary responsibility will be for services rendered and any applicable co-pays, deductibles, co-insurance, or other charges that are not covered but not subject to an ABN (for example failure to disclose open liability or open home health case can transfer financial liability to the patient). Payment can be made via check or credit card (processing fee applies for credit card).  If financial hardship applies, there will need to be a form filled out to validate and accept said hardship, this can be obtained by calling our facility.

While Evolution Rehab Group does its best due diligence to ensure coverage by your insurance plan, there is no absolute way to be 100% certain of coverage (for example outstanding claims maybe in the system processing or have not been submitted timely (up to a year to send in)and can skew what is known for coverage/deductibles).  For typical Medicare, Medicare will cover 80% of all charges, leaving 20% of charges to be the patient’s responsibility or to be covered by a secondary or supplemental insurance company.  This is roughly $20 for a 1 hour session.  Evolution Rehab Group will submit electronic claims on my behalf and will notify me via letter of any amount due in lieu of charges (co-pays/deductible) that would be collected at the time of service.  It is YOUR responsibility to notify Evolution Rehab Group of any of the following as it will likely terminate your coverage and leave you with full charges 1- Your primary insurance and or plan changes while under services 2-Your secondary of supplemental insurance plan changes while under services 3-You elect to enroll in an HMO or other plan that our group may not be member of 4-You have a third-party liability that is open that may make your regular insurance no longer the payer of record (for example a car accident with an open medical claim) 5-You are under a part A home health episode (nursing or therapy) Failure to notify Evolution Rehab Group prior to your service date, will result in full balance being charged to you directly. Note, in some rare instances, insurance companies mail the payment to the beneficiary instead of our company.  If this happens you will be responsible for signing the checks over to our company or writing a new check in the amount of the checks received.  We will contact you prior to starting services to go over your estimated out of pocket expenses which will include deductibles for your primary payer, co-insurance or co-pays, and any uncovered services. Deductibles or exclusions/limitations by your secondary/supplemental policies are not considered when checking and determining eligibility.  For example, if your secondary or supplemental only covers your 20% after a surgery, we will do our best to determine this, but if it is not seen on an electronic portal eligibility check, then it is not something we can readily know, and would be your responsibility to know your plan's benefits and coverages.  We can assist you on a call if you are in touch with your benefits management coordinators to help determine costs, but for the most part, Medicare covers a predictable 80% after the annual deductible and your secondary or supplemental will cover the remaining 20% assuming no exclusion or limits.   ​ I understand the benefit prediction based on eligibility check performed and discussed with me over the phone or in person and on this form. I can request a copy of this form and explanation to be sent to me via email or fax at no charge. I understand that I may be billed for services rendered according to my insurance plan benefits.  If I elect to go outside of my insurance, I will sign an Advanced Beneficiary Notice (ABN) that explains why I am going outside of my coverage, the amounts expected to be collected by Evolution Rehab Group, and in the case of Medicare, understand that a claim will still go to Medicare for a denial to allow a secondary or cash rate to be the payer.

This is just an estimate. It is only based upon the eligibility check we were able to perform. We cannot see if you are in a part A home health or hospice episode of care which would make all of our billing void and become your responsibility. We cannot know if you change insurance/payers during our episode of care until we have a denial which can be weeks into the care episode. Based upon what we found your out of pocket expenses are as follows:

Therapy takes commitment from the patient as much as the therapist.  We ask that you make yourself available for the recommended frequencies (typically 2-3 times per week).  This means not cancelling just because you are sore, or don’t feel 100%, or you have friends stopping by.  We ask that you perform all the home program activities recommended and are attentive and available for treatment as directed.  We also ask that you understand that most insurance plans ask for supervisory visits periodically to update progress, check on the plan of care, and make sure you are satisfied with care.  The supervisor will also need to come out for a final discharge assessment.  PLEASE, keep us informed if you have any changes to your medical condition, have been in the hospital/ER/Urgent care since your last session, have any new medications or diagnoses since your last session, or have changed insurance plans or coverage.  If you are not seen for a period of 15 days or more, we reserve the right to terminate services and have you obtain a new prescription and begin the care episode all over again.  If you do not cooperate with scheduling or our plan of care in this manner, we will notify you in writing of our intent to withdraw from your care and offer other options in the area for your therapy needs.  If you elect to cancel services or self-discharge before the planned episode is over or before a planned progress or discharge assessment, please let us know.   If we cannot accommodate your needs, if your environment is not safe for our therapists or your treatment sessions, we will not be able to provide care.  If you need translation services or any assistance communicating with our office or our clinical staff please let us know and we will provide these services at no charge.  We ask that you provide feedback at our website or by email to www.evolution.rehab or info@evolution.rehab both if you are happy with services or dissatisfied. Multiple cancels without 24 hours notice may be liable for our no show/cancel rate without 24 hour notice of $90 per session.  This is not reimbursable by your insurance, and will be due in full payment prior to your next session.  We grant 1 late cancel/no show per episode of care before implementing this charge.