Consent and Release Form Consent for Treatment: I consent to evaluation, treatment and care by Apollo Rehab staff and therapists.

Obligation for Payment: I hereby agree to pay for all services provided by Apollo Rehab, except those covered by insurance (which includes all commercial and government 3rd party payers. Such as HMO and Medicare) Apollo Rehab will assist in insurance coverage matters, but I understand that it is my responsibility to comply with all requirements for insurance coverage. In the event I fail to comply with any of the obligations on this section, I agree to pay any and all collection costs incurred by Apollo Rehab in the enforcement of this section.

Release of Information for Payment Purpose: I hereby authorize and consent to Apollo Rehab release of medical information to obtain payments as described in Apollo Rehab privacy notice.

Assignments of Benefits: I hereby irrevocably assign payments to Apollo Rehab for all medical benefits applicable and otherwise payable to me. Where Medicare and Medicaid benefits are applicable, I certify that the information given by me in applying for payment, under title XVII or XIX of the social security act is correct and request of said payment of authorized benefits are made on my behalf. I understand that I am financially responsible to Apollo Rehab for charges the carrier declines to pay. It is furthered agreed that any credit balance resulting from payment by my insurance or other sources may be applied to any other accounts owed to Apollo Rehab by the insured or dependents.

Cancellation, Rescheduling, No Show and Late Policy: In order to provide each patient with the highest quality service we ask that you call 24 hours in advance if you are unable to keep scheduled appointments. We also reserve the right to refuse treatment if you are late to scheduled appointments in order ensure appropriate time and personal attention to each patient.





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