Release of Information & Consent for Treatment
All information provided herein is true and correct.
I am aware of my diagnosis and wish to receive treatment at Robinet Physical Therapy. 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 this care.
I give permission to Robinet Physical Therapy to release information, verbal and written, contained in my medical record, and other related information, to my insurance company, rehab nurse, case manager, attorney, school, related healthcare provider, assignees and/or beneficiaries and all other related persons as it relates to my treatment or payment for services provided.
I authorize Robinet Physical Therapy to obtain medical records and /or professional information from my physician or other medical professionals as it relates to my treatment.