Consent to Obtain Electronic Medication History, Telephone Calls and Email Usage

I understand that my medication history may be obtained utilizing electronic information exchange and that this protected health information may provide valuable information for my healthcare provider. I hereby authorize Kleinert Kutz to access my medication history without limitation or exclusion as is required and/or reasonably advisable to disclose, process, retrieve, transmit and view for the purpose of the transmission of an electronic prescription issued by a provider authorized by law to prescribe, as necessary for my care and treatment. If at any time I provide a telephone number at which I may be contacted, I consent to receive calls or text messages, including but not restricted to communications regarding billing and payment for items and services, unless I notify the provider to the contrary in writing. In this section, calls and text messages include but are not restricted to pre-recorded messages, artificial voice messages, automatic telephone dialing devices or other computer assisted technology, or by electronic mail, text messaging or by any other form of electronic communication from the hospital, affiliates, contractors, servicers, clinical providers, attorneys or its agents including collection agencies. If at any time I provide my email address at which I may be contacted, unless I notify the provider to the contrary in writing, I consent to receiving communications regarding billing and payment for items and services at that email address from the hospital, affiliates, contractors, servicers, clinical providers, attorneys or its agents including collection agencies.

Consent to Treatment, Authorization to Release Information and Payment Information

I hearby consent to the rendering of care, including diagnostic procedure and treatment, as the attending physician or physicians under their supervision consider appropriate and necessary. I understand that I will be informed of the risks of any proposed procedures and treatment and I should decline treatment unless such risks are explained to my satisfaction. I also consent to the taking of any photographs, moving pictures, television and/or audiovisual aids in the course of medical treatment for the purpose of advancing medical knowledge through anonymous use in medical teaching, lecturing and/or anonymous publication in medical texts, journals or other medical publications.

Authorization to Release Information

I hearby authorize the release of information regarding my condition and treatment to any referring or consulting health care personnel or any health, liability or worker's compensation insurance carrier, agent, attorney or other representative purporting to act of my behalf, and any facility at which I may be treated, examined or evaluated. If I am here for an Independent Medical Exam or second opinion, I further authorize the release of information regarding my condition and treatment to the person or entity requesting such examination or opinion and to any agent, attorney or other representative of such person or entity.

Ancillary Services

I understand that I may be prescribed physical or occupational therapy, corrective appliances, devices and/or braces. I also understand that it is my responsibility to timely obtain authorization from my insurance carrier when required by my plan and be responsible for the payment of any such prescribed services. Kleinert, Kutz and Associates will assume no responsibility for the quality of the delivered product or service unless it has been acquired from the Christine M. Kleinert, Hand Therapy Center or Orthotic Care Center and the prescribed treatment protocol is followed.

Legal Process

In the event I, on behalf of myself or my child or ward, pursue personally, or through the efforts of an attorney, a claim against any part for the personal injuries being treated by Kleinert, Kutz and Associates, I will be responsible for notifying the payer and/or responsible person, that out of the proceeds of any settlement or judgment, Kleinert, Kutz and Associates is to be paid for services in full. I also will notify Kleinert, Kutz and Associates of my pursuit of such claim. In the event that I obtain any attorney, I agree to notify such attorney of this agreement which I have hereby made with Kleinert, Kutz and Associates and further authorized Kleinert, Kutz and Associates to provide my attorney with a copy of this agreement and any other information requested by this attorney. I understand that by receiving services from Kleinert, Kutz and Associates and/or its entities, I agree that I am solely responsible for payment of all medical bills upon receipt of said services. Kleinert, Kutz and Associates make no agreement not to proceed with normal collection activity on my unpaid balances.

Assignment of Insurance Benefits

I hearby authorize my current insurance carrier to pay Kleinert, Kutz and Associates out of any benefits due on this claim. I understand that I am financially responsible to the doctor for any charges not covered under this assignment (a copy is as valid as the original).

Payment for Services

I understand that Kleinert, Kutz and Associates may or may not be a participating provider with my insurance carrier and it's my responsibility to verify this status with my insurance. I understand as the patient, Kleinert, Kutz and Associates will file all insurance claims as a courtesy. I also understand that my insurance is a contract between my employer, the insurance company and me and that Kleinert, Kutz and Associates is not a party to that contract. I understand as the patient that I am responsible for all charges from the dates the service is rendered. I agree that any additional requests for information from my insurance company regarding coverage, coordination of benefits, dates of injury, or any related questions will be answered by me in a timely manner, or the balance due will become my responsibility. All co-payments, deductibles and past balances are due at the time of service. The only exception is if I have a verified worker's compensation claim. If Kleinert, Kutz and Associates are not a participating provider with my insurance, I will pay for services on the date they are rendered until a claim is established with my insurance company. This may include office visits, x-rays, orthotic devices, therapy or other services. In the event this matter is referred to Collections, I agree to pay all court costs, collection fees and attorney fees associated with the collections of this account.

**Kleinert Kutz has the right to charge my account $25 if I fail to give a 24-hour cancellation notice.** THIS IS A LEGALLY BINDING DOCUMENT - READ BEFORE SIGNING

I understand and agree that all of the provisions of this CONSENT TO TREATMENT, AUTHORIZATION TO RELEASE INFORMATION, AND PAYMENT INFORMATION shall remain in full force and effect until revoked by me IN WRITING.