I hereby give my permission to Abingdon Therapy Services, Inc. (ATS) to treat me, the minor named on this form. I further authorize payment by my insurance company on my behalf or on behalf of the named minor for such treatment. In connection therewith, I authorize ATS to release all information for services performed to my insurance company (which term includes any insurance carrier, or any other party contractually obligated to pay in whole or in part for my medical treatment). I understand that I am financially responsible for all charges not covered by my insurance company, and agree to pay ATS for such charges within 30 days of any invoice from ATS. Similarly, I understand that I am responsible for any supplies I receive from ATS to the extent my insurance does not cover such item. I agree to pay ATS for such uncovered items within thirty days of any invoice from ATS. I understand and agree that in the event I fail to pay ATS for services or supplies that are not paid by my insurance company, I will be responsible for all costs of collection incurred by ATS for such amounts, including reasonable attorney fees.
I understand and agree that photographs, videotapes and digital or other images may be recorded to document my care. I understand that ATS will retain ownership rights to such photographs, videotapes, and digital or other images. I will be allowed access to view, or to obtain copies of, such photographs, videotapes, and digital or other images. These images will be stored in a secure manner that will protect my privacy and will be kept for the time period required by law or otherwise outlined in ATS’s policy. Images that identify me will be released and/or used outside the institution only upon written authorization from me or my legal representative.
For Medicare recipients: I request that payment of Medicare benefits be made on my behalf to ATS for services or for items furnished to me by ATS and /or its associates. I authorize the release of any medical information about me needed to determine whether such benefits are payable.