ASSIGNMENT OF BENEFITS | RELEASE OF MEDICAL RECORDS | CONSENT FOR TREATMENT

I hereby authorize payment directly to Ozark Rehab and Therapy for services rendered and supplied by Ozark Rehab and Therapy therapists and staff.  I understand that this assignment is for all benefits otherwise payable to me, but not to exceed my indebtedness to Ozark Rehab and Therapy. I understand that I am financially responsible to Ozark Rehab and Therapy for charges not covered by my insurance for this treatment.  I authorize release of any medical records required for processing of claims. I request that payment of benefits due to me be made directly to Ozark Rehab and Therapy for services rendered. I authorize consent to be treated by all staff of Ozark Rehab and Therapy

AGE OF CONSENT WHERE MINORS ARE INVOLVED, THE FOLLOWING SHALL PREVAIL:

1. THE CONSENT OF A PARENT OR LEGAL GUARDIAN OF PATIENT IF PT IS UNMARRIED AND UNDER THE AGE OF 18.

2. IF A PATIENT UNDER 18 YEARS OF AGE, IS MARRIED, OR HAS BEEN MARRIED AND DISSOLVED BY DISSOLUTION OR ANNULMENT, THEN THE  CONSENT OF A LEGAL GUARDIAN IS NOT REQUIRED.

The undersigned further acknowledges that he/she has read and fully understands the foregoing, and has voluntarily executed this document.  The undersigned further acknowledges that he/she is the patient, or is duly authorized by and on behalf of the patient to execute this document, and accepts its terms personally upon patient’s behalf.  The release of information set forth hereinabove is valid, and the assignment of benefits and financial agreement is valid and binding until final settlement of the account is received.


Patient Name *
Patient Name
Date of Birth
Date of Birth
Date of signature *
Date of signature
Date of Signature *
Date of Signature