Consent to Treatment
I hereby consent to the delivery of services and treatment(s) by the providers and staff members of LifeCare Alliance. I have received a statement of my rights and responsibilities as a patient, and that those rights and responsibilities have been reviewed with me and/or my representative.

Consent to Use and Disclose Your Health Information
1. I hereby authorize LifeCare Alliance to use and/or disclose my health information for treatment, payment or health care operations.
2. I have the right to refuse to sign this consent. If I refuse to sign this consent, LifeCare Alliance has the right to refuse to treat me.
3. I have the right to request that LifeCare Alliance restrict the use and/or disclosure of protected health information for the purpose of providing treatment, obtaining payment for services, and/or conducting heath care operations. Such requests must be made in writing to LifeCare Alliance. LifeCare Alliance is not required to agree to any restriction I may request. If, however, LifeCare Alliance does decide to agree to such restriction(s) I request, LifeCare Alliance must restrict the use and/or disclosure of my health information in the manner described in my request. To obtain a restriction request form, please contact the Privacy Officer at LifeCare Alliance, 1699 West Mound Street, Columbus, OH 43223 or (614) 278-3130.
4. I have a right to receive a copy of this form after I sign it. This consent is effective for one year from the date signed, unless I revoke it in writing. Revocation will not be effective for disclosures already made in reliance to my prior consent. LifeCare Alliance has the right to refuse to provide further treatment if I revoke my consent.
5. I hereby authorize LifeCare Alliance to leave a message on my home and/or cell phone regarding my health information.
6. I hereby authorize LifeCare Alliance to speak to my emergency contact regarding my health information.
7. LifeCare Alliance participates in one or more Health Information Exchanges. Your healthcare providers can use this electronic network to securely provide access to your health records for a better picture of your health needs. We, and other healthcare providers, may allow access to your health information through the Health Information Exchange for treatment, payment or other healthcare operations. This is a voluntary agreement. You may opt-out at any time by contacting the Privacy Officer at LifeCare Alliance, 1699 West Mound Street, Columbus, Ohio 43223 or (614) 278-3130.
Billing Consent
I understand and agree to the following, as it relates to my insurance, and the services that I will receive at LifeCare Alliance:
1. It is my responsibility to verify with my insurance company if services are covered, and if LifeCare Alliance is in or out of network with my insurance plan.
2. It is my responsibility to determine if a prior authorization is required, before services are rendered to me.
3. In the event that my physician or I have requested services that are not eligible under my insurance benefits, I will be fully responsible for all charges related to the service(s) rendered to me.
4. If I have provided inaccurate or incomplete information to LifeCare Alliance, relating to my insurance benefits, and the information is not corrected before the filing limit, I will be responsible for all charges denied by my insurance company.
5. I can make payment arrangements for the portion of the bill that my insurance company does not pay.
6. Financial assistance is available for those who qualify.
I certify that the information given by me in applying for third party payment is complete and correct to the best of my knowledge.
1. I authorize any holder of medical or other information about me be released to the Health Care Financing Administration, or its intermediaries or carriers, needed for any health care claim made by LifeCare Alliance.
2. I request that the payment of authorized benefits be made on my behalf, and that the benefits be made payable for covered services rendered by LifeCare Alliance.
3. I request that the payment for services under my medical insurance coverage be made payable to LifeCare Alliance.
4. I authorize LifeCare Alliance to furnish complete information to my insurance carrier or its intermediaries in relation to services rendered.
5. I understand that I am responsible for payment of charges (if applicable) left unpaid by my insurance carrier or other third party payers.
6. I will uphold any payment schedule agreement negotiated with LifeCare Alliance.
Use and Notice of Private Health Information
I understand that my signature on this form acknowledges that I have a right to request a copy of LifeCare Alliance's Notice of Privacy Practices. I understand that this document provides an explanation of the ways in which my health information may be used or disclosed by LifeCare Alliance, and of my rights with respect to my personal health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.