INSURANCE APPLICATION & AUTHORIZATION

PATIENT INFORMATION

PRIVATE INSURANCE INFORMATION

POLICY HOLDER INFORMATION (Only if different from Patient)

CONSENT TO COLLECT & EXCHANGE PERSONAL INFORMATION

Message to the Plan member, Spouse and/or Dependent regarding Personal Information:

Personal information that we collect and disclose about you, and if applicable, your spouse and/or dependents, is used by the insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering the group benefits plan, including the investigation of fraud and/or plan abuse.

AUTHORIZATION & CONSENT

I authorize my healthcare provider/Cogent Physical Rehabilitation Center to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or administrator and their service provider(s) for the above purposes. I authorize the insurer and/or plan administrator and their service provider(s) to:

• Use my personal information for the above purposes.

• Exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits or other benefits programs relevant for the above purposes.

• Exchange personal information concerning any claims submitted with the plan member or person acting on behalf of the plan member.

• Exchange personal information for the above purposes electronically or in any other manner. I understand that personal information may be subject to disclosure to those authorized under applicable law.

I agree that this signed form and photocopies of this signed form will serve as authorization to Cogent Physical Rehabilitation Center and may remain in effect for the continued administration of the group benefits plan.

DIRECT BILLING POLICY

• This signed form and photocopies of this signed form will serve as as an agreement to provide payment directly to Cogent Physical Rehabilitation Center at the time of each visit, and later claim through any extended health benefits plan, as appropriate.

• Cogent Physical Rehabilitation Center will present a receipt for every payment received at the clinic.

• Payment for service rendered would be made for each service using a credit or debit card, cash or band transfer.

  
  

Please check the box below to indicate that you agree to abide this policy

SIGN AND SUBMIT