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  • MTS Patient Agreement

  • BEFORE COMPLETING - are you currently receiving ANY home medical services? (home nursing, physical/occupational/speech therapy, wound care) IF YES - please call - 949.529.1567

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  • This agreement and signature below (by patient or authorized representative) is established to allow the above patient to receive skilled therapy services from a licensed therapist of Mobile Therapy Specialists Inc. Patient certifies that all information given in applying for payment under TITLE XVIII and XIX of the Social Security Act is correct.

    TREATMENT CONSENT

    By signing below, patient consents to receive skilled therapy treatment from the licensed therapist as assigned by Mobile Therapy Specialists Inc. Patient further acknowledges that no guarantees have been made as a result of this treatment.

    ASSIGNMENT OF INSURANCE BENEFITS

    Patient hereby authorizes Mobile Therapy Specialists Inc. to invoice and receive any INSURANCE BENEFITSand all payment for services from any type of insurance including third party payors.

    GUARANTEE OF ACCOUNT

    Patient recognizes he/she is financially responsible for payment of services not otherwise covered including insurance denials, deductibles and copayment fees. Patient further understands that the temporary acceptance of verified insurance coverage in lieu of payment does not release the patient from ultimate payment responsibilities. If legal proceedings are necessary to pursue payment, the patient or authorized representative agrees to pay all fees and costs.

    RELEASE OF INFORMATION

    Patient consents and agrees to permit release of any and all patient medical records and related information to insurers and other entities directly involved in his/her care, now or in the future, as required by law.

    HIPAA PRIVACY POLICY

    Patient acknowledges receipt of the Notice of Privacy Practices from Mobile Therapy Specialists Inc. website. Patient understands that by initialing and signing, he/she has been informed of HIPAA Privacy Policy information. 

  • CANCELLATION POLICY

    Patient understands that late cancellations less than 24 hours in advance and all no-show appointments will be billed directly to the patient at a cost of $60 per visit. This cost is not covered by your insurance. 

  • CERTIFICATION: With the signature below, the patient and/or authorized representative certifies that he/she has read through all information above, has received a copy, and is willing to abide by all agreements. In addition, he/she approves email/text communication and certifies that all information provided here and over the phone is accurate.

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  • PATIENT MEDICAL HISTORY

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  • Please list any medications you are currently taking:

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  • Should be Empty: