Patient Consent Form

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

Baker Rehab Group and its affiliated companies (“Provider”), may use and disclose your protected health information for treatment, payment and healthcare operations in accordance with the Health Insurance Portability and Accountability Act (“HIPAA”) as amended and implemented by regulations of the federal Department of Health and
Human Services (“Regulations”). The use of “you” or “your” below, where in context, also refers to your authorized representative(s).

Consents: In accordance with Regulations, Provider exercises its option to obtain your consent regarding the use and disclosure of your information at the start of care or within a reasonable amount of time afterwards. Provider maintains the right not to provide treatment if you refuse to sign the consent form.

Authorizations: Your written authorization is required for the disclosure of your protected health information when the disclosure is not for treatment purposes, Provider operations, payment, or required by law.

Your health information may be used and disclosed:

To Provide Treatment by Provider and to others involved with treatment (such as your attending physician, family member, pharmacists, suppliers of medical equipment or other health care professionals). For example, your attending physician may need information about your symptoms in order to prescribe appropriate medications. Where applicable, any documents containing protected health information given to you or left in your home by one of your caregivers for the purpose of treatment instruction and/or continued care, is your responsibility to safeguard.

To Obtain Payment. Provider may disclose your health information to collect payment from third parties. For example, Provider may be required by your health insurer to disclose information regarding your health care status to obtain prior approval for treatment.

To Conduct Health Care Operations to facilitate the function of Provider and as necessary to provide quality care to all of Provider’s patients; include such activities as:

• Quality assessment and improvement
• Activities designed to improve health and reduce health care costs
• Protocol development, case management and care coordination
• Contacting providers and patients about treatment alternatives and other related functions
• Professional review and performance evaluation
• Supervised professional training programs
• Accreditation, certification, licensing or credentialing
• Review and auditing (including compliance, medical, and legal services)
• Business planning and development (includes cost management, analyses, and formularies)
• Business management and general administration

For example, Provider may use your health information to evaluate its staff performance, combine your health information with other Provider patients in evaluating how to more effectively serve all Provider patients, disclose your health information to Provider staff and contracted personnel for training purposes, use your health information to contact you as a reminder regarding a visit to you, or contact you via information mailings (unless you tell us you do not want to be contacted for such).

To Business Associates. We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of Provider. For example, we may disclose your protected health information to Business Associate to administer claims. Business Associates are also required by law to safeguard your protected health information.

For Appointment Reminders. Provider may use and disclose your health information to contact you as a reminder that you have an appointment with said Provider.

For Treatment Alternatives. Provider may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Financial Agreement and Assignment of Benefits

I hereby authorize Homecare Rehab and Nursing LLC referred to herein as "Baker Rehab Group" to administer treatment required for my diagnosis, to apply for benefits from my insurance carrier(s) listed able, and I authorized payment of the medical benefits directly to Baker Rehab Group, if any, otherwise payable to me for services rendered by Baker Rehab Group. Further, I authorized Baker Rehab Group to disclose complete medical information concerning the diagnosis for which I am being seen to any other payer or collateral that will pay part or all of these medical bills.

I understand that all financial obligations for services are due from me when treatment is rendered. I also understand that I am completely responsible for medical treatment, including any fees charged for returned checks, regardless of any payer, third-party interest, or the resolution of any legal action or lawsuits in which I may be involved. Paying by check authorizes Baker Rehab Group to use the information from your check to make a one-time electronic fund transfer from your account. Funds may be withdrawn from your account as soon as your payment is received. If we cannot process the transaction electronically, you authorize Baker Rehab Group to present an image copy of your check for payment. Your original check will be destroyed once processed. If your check is returned unpaid you agree to pay Baker Rehab Group an NSF fee of $25. Returned checks may be presented electronically.

I further understand that Baker Rehab Group reserves the right to pursue delinquent accounts via third -party collection agencies or attorneys. In the event my bill is referred for collection, I agree to pay all collection agency fees, attorne fees, court costs, service of process fees and any late charges per month for all balances over 30 days, in addition to the amount owed for services rendered (as applicable by state guidelines). I understand that by providing my email, landline or cell phone number(s), I give my consent for Baker Rehab Group, its agents, and its collection agents, to contact me at these email addresses or numbers, or, at any number that is later acquired for me, and, to leave live, SMS text or pre-recorded messages regarding any accounts, or services. For greater efficiency, calls may be delivered by an auto dialer. I understand that providing a telephone or cell number is not a condition of receiving services, however, the cell phone number I provide may also be used for an in-house text message survey. Baker Rehab Group may use this to gauge how their clinics and staff are performing. I may opt out at any time by texting the word "stop." Message and Data rates may apply. This agreement is a contract under seal and shall be considered a specialty contract.