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CGPT Policy Patient Agreement Form NOTIFICATION OF PATIENT RESPONSIBILITY Columbia Gorge Physical Therapy Sports Medicine verifies your benefits with your insurance carrier but does not guarantee any information given to us regarding benefits authorization or network plan. We advise that you check with your health plan for a complete understanding of what will be billed to you. If the information provided by your insurance company or by you is not accurate or the insurance company changes its coverage you will be responsible for payment for services. All applicable fees co-pays or supply purchases must be paid at the time of your appointment. We accept cash checks VISA MasterCard. CANCELLATIONS We are entering into a cooperative partnership with you and your physician to help you attain you maximal rehabilitation goals. We understand that circumstances may arise requiring you to cancel your scheduled appointment. However cancellations have a serious impact on the clinic and continuous No Shows will be handled on a case by case basis and may be subject to a fee for that missed visit if you need to cancel your appointment please be sure to call us at 541-386-1211 at least 24 hours before your scheduled appointment time. CONSENT FOR TREATMENT AND RELEASE OF INFORMATION a* I am aware of my diagnosis and wish to receive treatment from CGPTSM. I permit its employees and all other persons caring for me to treat me in ways they judge are beneficial to me. I understand that this care can include an evaluation testing and treatment. No guarantees have been made to me about the outcome of the care. b. I give permission to CGPTSM to release information verbal and written contained in my medical record and other related information to my insurance company rehab nurse case manager attorney employer school related healthcare provider assignees and/or beneficiaries and all other related persons as it relates to my treatment and/or payment for services provided* c* I authorize CGPTSM to obtain medical records and/or professional information from my physician or other medical professional as it relates to my treatment. APPOINTMENT REMINDERS TEXT MSG Phone Call CHANGE OF INFORMATION Please provide us with any changes regarding your address telephone number s or insurance information as soon as possible so we can update our records. CELL PHONES Please keep your cell phone turned off during your appointments as a courtesy to our patients and staff* FRAGRANCES / PERFUME / COLOGNE Due to allergies or patient sensitivity we ask that you please help us try and keep this environment fragrance free. I the Guarantor and Responsible Party agree to the above policies and agree to the terms regarding payment and responsibilities. If the information provided by your insurance company or by you is not accurate or the insurance company changes its coverage you will be responsible for payment for services. All applicable fees co-pays or supply purchases must be paid at the time of your appointment. We accept cash checks VISA MasterCard.

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