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Consent for Care

I hereby give my consent to Petkov Bodywork Therapy, LLC to provide care and services prescribed by my physician, both verbally and written. I also give my consent to exercise professional judgment in any additional care and services that may be necessary. My consent for care is extended to the said staff of the said agency providing occupational therapy. Instructions for my care are explained to me and I understand my obligation to follow the home program and any other recommendations given to me to the best of my ability.

I am also made aware that therapy services may result in one or all of the following: increased pain, increased swelling, increased redness, burning sensations and wound bleeding.

Assignment of Benefits

I Thereby authorize and direct my insurance carrier (including Medicare, private insurance and any other health/medical plan) to issue payment directly to Petkov Bodywork Therapy, LLC for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. It is my understanding that any money received over and above my indebtedness will be refunded to me when my bill is paid in full. I understand that I am responsible for any and all charges not covered by my insurance company any fees assigned by a collection agency or an attorney. A photocopy of this assignment is to be considered as valid as original. This will remain in effect until revoked by me in writing.

Authorization to Release Information

I hereby authorize Petkov Bodywork Therapy, LLC to (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used in processing insurance claims for the period of a lifetime. This order will remain in effect until revoked by me in writing. I have requested medical services from Petkov Bodywork Therapy, LLC. On behalf of myself and/or my dependents, and understand that my making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

Kindly read more about our payment policy, health policy, duties and responsibilties, disclosure policy, your rights and more at our Policy and Information page.

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At the submission of this form, we will contact you shortly. The generated form would be sent to your given email address.

[email protected]

Our outpatient therapy services are available anywhere in Phoenix, Glendale, Peoria, Surprise, Sun City, East valley and West valley of Arizona and the Surrounding Communities.

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