I authorize any holder of medical or other information about me to be released to LimbTech, their assignees or successors, such as communication being needed to determine benefits payable for related claims for supplies or services furnished by LimbTech. I authorize LimbTech to file my insurance claims and to release any medical information needed to my insurance company to process any medical claims. This authorization does not have an expiration date. It Is my right to cancel this request at any time, however, it need to be done in writing. I understand that the information obtained may be subject to re-disclosure to a third party by LimbTech.
I authorize my insurance company to pay benefits directly to LimbTech. I understand I am responsible for the cost of the yearly deductible, co-insurance, copayments, and/or non-covered items. If the patients balance is not paid as agreed, the balance will be turned over to an outside collection agency. I understand there will be a $25 charge for any checks returned for insufficient funds. I may also be charged services fees if patient request PayPal or other payment options are available. LimbTech will discuss these fees with patient before charges are applied.
I authorize any photography of me and/or my medical device by LimbTech, in connection with my diagnosis, treatment, or for reimbursement purposes. Photographs will be incorporated within the patient’s medical record for documentation of care.
Notice of Privacy Practice: You have the right to read our Notice of Privacy Practice before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. We encourage you to read it carefully and completely before signing the consent. Purpose of Consent: By signing this form, you will consent for LimbTech to use and disclose your protected health information to carry out treatment, payment activities, and healthcare operations.
“The product and/or services provided to you by LimbTech are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57 (c). These standards concern businesses professional and operations matters (e.g., honoring warranties and hours of operation). The full text of these standards can be obtained at http://ecfr.gpoacess.gov Upon request, we will furnish you a written copy of the standards.”
I hereby certify that I have read and fully understand and consent to the above provisions.
LimbTech
186 Butler Ridge Trail Hendersonville, NC 28792 US
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