I hereby consent and authorize the adminstration of all procedures. I authorize Under Pressure Therapeutics to release or obtain any information to the insurance company, attorney, or referring physician upon request. I also assign and request payment of medical benefits to Under Pressure Therapeutics. I also understand that I am financially responsible for any charges not covered by my insurance carrier.
I ackowledge the following policies and procedures held by Under Pressure Therapeutics and will abide by and respect the following:
To: Attorney / Insurance Carrier:
RE: Patient Records and Massage Therapist's Lien
I do hereby authorize Under Pressure Therapeutics located at 1918 S Lemay Ave, Suite A, Fort Collins, CO 80525 to furnish you, my attorney / insurance carrier, with a full report of my case history, examination, diagnosis, treatment, and prognosis of myself in regard to my accident / illness which occured / began on ___ / ___ / _____.
I hereby give a lien to Under Pressure Therapeutics on any settlement, claim, judgement, or verdict as a result of said accident / illness, and authorize and direct you, my attorney / insurance carrier to pay directly to Under Pressure Therapeutics such sums as may be due and owing them for service rendered me, and to withhold such sums from such settlement, claim, judgement, or verdict as may be necessary to protect Under Pressure Therapeutics acequately.
I fully understand that I am directly and fully responsible to Under Pressure Therapeutics for all medical bills submitted by them for services rended me, and that this agreement is made solely for the Under Pressure Therapeutics' additional protection and in consideration of my awaiting payment. And I further understand that such payment is not contingent on any settlement, claim, judgement, or verdict by which I may eventually recover said fee.
By signing this form, I authorize you to release confidential health information about me by releasing a copy of my medical record, or a summary or narrative of my protected health information, to the physician / person / facility / entity listed below.