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Alliance Therapy Services |
| Admit/Medical History Form - Page 2 |
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Family History
Has any blood relative ever had any of the following:
Cancer............................... [ ] Yes [ ] No Stroke.............................[ ] Yes [ ] No
Arthritis.............................. [ ] Yes [ ] No Gout...............................[ ] Yes [ ] No
Diabetes............................. [ ] Yes [ ] No [ ] Yes [ ] No |
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Medications
Please list ALL present medications:
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Surgery
Please list ALL previous operations, fractures and other serious injuries:
Date Surgery Age
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| Conditions and Admission to Alliance Therapy Services, Inc.: |
| Release of Information. The agency may disclose all or any parta of the patient's record to any person or corporation which is or may be liable under a contract to the agency or to the patient or to a family member or employer of the patient for all or part of the agency's charge, including but not limited to, hospital or medical service companies, insurance companies, workmen's compensation carriers, welfare funds, or patient's employer. |
| Treatment Consent. The patient is under the control of his/her physician, and the undersigned consents to any treatment or procedures rendered the patient by the agency under the general and specific instructions of the physician. It is further understood that the agency is authorized to carry out all instructions of the patient's doctor and that the agency is hereby relieved of any and all liability occurring from the performance of the doctor's instructions. |
| I request and authorize staff of Alliance Therapy Services, Inc. to provide me with treatment, and to perform any procedures now contemplated or such additional procedures as y doctor may deem reasonable and necessary. |
| I authorize Social Security Administration to disclose information regarding my Medicare coverage, including but not limited to, verification of my Medicare number, effective dates, and type of coverage. |
| Assignment of Benefits. I hereby authorize my insurance company to pay directly to Alliance Therapy Services, Inc. all benefits due me, if any, by reason of services described in the statements rendered, and as provided for in the above policy contract with insurance company. I understand that Alliance Therapy Services, Inc., which has accepted assignment, has the same right as I do to appeal carrier's determination. |
| The undersigned certifies that he/she has read the foregoing and is the patient, or is duly authorized by the patient as patient's general agent to execute the above and accept its terms. It is further understood that this release remains in effect for one (1) year unless otherwise revoked. |
Financial responsibility. I hereby accept all responsibility for treatment costs not covered or reimbursed by third-party payers. The undersigned certifies that he/she has been explained the treatment costs and is the responsible party and accepts these terms.
Patient Signature: __________________________________ Date: _________________________
Signature of Person Authorized to Sign in Lieu of Patient:
_________________________________________________ Date: _________________________
Relationship to Patient Reason why Patient is unable to sign |
