I hereby authorize Optimum Health and Wellness Physical Therapy, Inc. (hereafter referred to as OHWPT, Inc.) and/or its affiliates, employees, or agents to perform physical examination and/or medical treatment as directed by my referring provider. This includes, but is not limited to, required medical examinations, therapeutic procedures, evaluations, and ongoing treatment to be carried out by the designated staff. (Please initial )
I hereby authorize OHWPT, Inc. and/or its affiliates to disclose to my employer (only under Workmen's Compensation), prospective employer, insurance company, and/or third-party payer any pertinent medical information, test results and findings made during the course of this examination and/or treatments. I also authorize OHWPT, Inc. and/or its affiliates to release any medical information, test results, and any appropriate information concerning my medical history, examinations, treatments, or other diagnostic procedures, including copies of my records to official requesters, including but not limited to insurance companies, third party administrators, utilization review organizations, health care service plans, or to any other person or entity as necessary in connection with certification, payment, or reimbursement for services rendered. I further acknowledge that release of such information is pursuant to the following paragraph. (Please initial )
It is the policy fo OHWPT, Inc., and its affiliates, to protect all medical records against loss, tampering, destruction, and access by unauthorized persons. I understand that medical records may be periodically reviewed by national accreditation or certification surveyors and other necessary quality assurance personnel, and I authorize such release of information. I further acknowledge that my records and associated documentation may be disclosed to third parties including government agencies, as required by Law, including but not limited or pursuant to warrant, subpoena, or court order, and I hereby agree not to pursue any action against OHWPT, Inc. and/or its affiliates for any damages I may suffer as a result of such disclosure. (Please initial )
Is the patient a minor? If yes, Parent/Guardian initial below. Yes No As a parent and/or legal guardian, I authorize OHWPT, Inc. to treat the minor patient named in the attached forms while I am not present. (Please initial )
By signing this authorization form I acknowledge that I have fully read or had this form read/or explained to me, and that I fully understand its contents. I have been given ample opportunity to ask questions, and any questions have been answered satisfactorily.
Would you like to be added to our mailing list? Yes NoParent/Legal Guardian or Representative (If applicable) Date
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Document Name: Patient Authorizations
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