Get Patient Authorization Form - Paladin Physical Therapy

Filling out the Patient Authorization Form is an essential step in receiving treatment at Paladin Physical Therapy. This guide provides straightforward instructions to help you complete the form accurately and efficiently online.

Follow the steps to fill out the form successfully.

1. Click ‘Get Form’ button to access the Patient Authorization Form and open it in your preferred online editor.
2. Begin by filling out your personal information at the top of the form, including your full name, date of birth, and contact information.
3. In the Authorization for Treatment section, initial the provided space to confirm your consent for rehabilitation procedures as deemed necessary by your therapist.
4. In the Authorization for Release of Information section, read the statements carefully. Indicate your agreement by initialing next to each point that allows Paladin Physical Therapy to share and obtain necessary medical information.
5. Moving to Authorization for Release of Payment, initial to permit direct payment of benefits from your insurance to Paladin Physical Therapy for the services provided.
6. Complete the Patient Agreement section by initialing to confirm your responsibility for any charges not covered by insurance and acknowledging potential collection costs.
7. In the Medicare, Medicaid, and Similar Benefits section, fill in your information accurately and initial to agree that it is complete and correct.
8. For the Workers Compensation section, provide accurate details and initial to confirm your agreement with the statements regarding claims processing.
9. At the bottom of the form, provide your signature and date to officially authorize the information you provided, and ensure that you print your name in the designated area. If applicable, a witness may also need to sign.
10. Finally, if you have a legal representative or power of attorney, they should sign the form in the specified section to complete the process.
11. After reviewing the completed form for accuracy, save your changes, and utilize available options to download, print, or share the form as needed.

Complete your Patient Authorization Form online today to ensure prompt and effective treatment.