Statement Of Financial Responsibility Form - 2009


Statement of Financial Responsibility
Patient Name: ______________________________________ Date: _________
Acct #: _______________________
Select Medical appreciates the confidence you have shown in choosing us to provide for your rehabilitative needs. The service
you have elected to participate in implies a financial responsibility on your part. This responsibility obligates you to ensure
payment in full of your fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However,
you are ultimately responsible for the payment of your bill.
You are responsible for payment of any co-payment at the time of service and on receipt of a bill for any deductible /coinsurance
as determined by your contract with your insurance carrier. Many insurance companies have additional stipulations that may affect
your coverage. You are responsible for any amount not covered by your insurer. If your insurance carrier denies any part of your
claim, or if you and your physician elect to continue therapy past your approved period, you will be responsible for your account
balance in full.
I have read the above policy regarding my financial responsibility to Select Medical for providing rehabilitative services to the
above named patient or me. I certify that the information provided is, to the best of my knowledge, true and accurate. I authorize
my insurer to pay any benefits directly to Select Medical. I agree to pay Select Medical the full and entire amount of all bills
incurred by me or the above named patient, if applicable, any amount due after payment has been made by my insurance carrier.
Signature: ___________________________________(
Date: __________
relationship to patient: self - guardian - other: __________)
There may be times when it is necessary for an individual directly involved in your care to call the facility to inquire
about your personal health information or billing information. Please take a few moments to complete this section.
I authorize Select Medical to disclose my health information that is directly related to my current treatment at Select
Medical to the individual(s) listed below for purposes of their role in my treatment or payment for the health services
that I have received.
Such persons involved in your care may include: spouse, children, blood relatives, roommates, boyfriends/girlfriends,
domestic partners, neighbors and colleagues.
I do not wish to have my health information disclosed to individuals involved in my care.
I acknowledge that the Notice of Privacy Practices is posted at the location in which I am receiving treatment and that I
have read and understand the notice. I further acknowledge that I have the right to request a copy of the notice and one
will be provided to me.
Signature : _______________________________________(
Date : __________
relationship to patient: self - guardian - other: __________)
I hereby authorize Select Medical through its appropriate personnel, to furnish medical care and treatment to me, or the above
named patient, considered necessary and proper in diagnosing or treating my/his/her physical condition.
Signature : _______________________________________(
Date : __________
relationship to patient: self - guardian - other: __________)
I further authorize Select Medical to release to appropriate agencies, any information acquired in the course of my or the above
named patient’s examination and treatment necessary to secure payment for services provided.
Signature : ______________________________________
Date : _________
(relationship to patient: self - guardian - other: ____________)
Form Version-Internet 4/2009


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