I voluntarily consent to the rendering of such care and treatment as my providers, in their professional judgment, deem necessary for my health and well-being; however I may refuse any particular treatment or procedure.

If I request or initiate a Telehealth visit (a "virtual visit"), I hereby consent to participate in such Telehealth visit and its recording and I understand I may terminate such visit at any time.

My consent shall cover medical examinations and diagnostic testing (including testing for sexually transmitted infections and/or HIV, if separate consent is not required by law), including, but not limited to, minor surgical procedures (including suturing), cast application/removals and vaccine administration. My consent shall also cover the carrying out of the orders of my treating provider by care center staff. I acknowledge that neither my provider nor any of his or her staff have made any guarantee or promise as to the results that I will obtain.

I hereby certify that the insurance information I have provided is accurate, complete and current and that I have no other insurance coverage. I assign my right to receive payment of authorized benefits under Medicare, Medicaid, and/or any of my insurance carriers to the facility or supplier of any services furnished to me by that facility or supplier. I authorize my facility to file an appeal on my behalf for any denial of payment and/or adverse benefit determination related to services and care provided. If my health insurance plan does not pay my provider directly, I agree to forward to my provider all health insurance payments which I receive for the services rendered by my provider and its health care providers.

I understand that if my provider does not participate in my insurance plan\'s network, or if I am a self-pay patient, this assignment of benefits may not apply. In consideration of the services provided by my provider, I agree that I am responsible for all charges for services I receive that are not covered by my health insurance plan or for which I am responsible for payment under my health insurance plan. I agree to pay all charges not covered by my health insurance plan or for which I am responsible for payment under my health insurance plan. I further agree that, to the extent permitted by law, I will reimburse my provider for all costs, expenses and attorney\'s fees incurred by my provider to collect those charges.

If my insurance has a pre-certification or authorization requirement, I understand that it is my responsibility to obtain authorization for services rendered according to the plan\'s provisions. I understand that my failure to do so may result in reduction or denial of benefit payments and that I will be responsible for all balances due.

I explicitly authorize Boston Brain Center to coordinate, access, process, and release necessary metrics of my Protected Health Information (PHI) in complete adherence to strict federal privacy guidelines. This includes treatment notes, laboratory outputs, diagnosis registries, billing allocations, and related physical rehabilitation parameters.

Information about alcohol/substance use, HIV/AIDS, and mental health issues is included unless I specifically request that it be excluded below. Psychotherapy notes, however, are never included. If I request we send only a portion of my records to a treating provider, I understand that incomplete records will be sent to me to give to my provider; incomplete records will not be sent directly to a treating provider.

I understand that I have the right to receive a copy of my PHI in the form and format and manner I request, if readily producible in that way, or as I may otherwise agree. If I do not specify a format, I understand that my PHI will be mailed to me at the address listed above in hard copy/paper format. I may request that my PHI be provided via secure electronic delivery or other format, and if I request records be sent unencrypted, I understand and acknowledge the risk of sending my PHI in an insecure manner.

I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or entity receiving it and will then no longer be protected by federal privacy regulations. I understand I may revoke this authorization by notifying my provider or contact@bostonbraincenter.org in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I understand that my care and treatment may not be conditioned on providing this authorization, if such conditioning is prohibited by the HIPAA Privacy Rule.

My purpose/use of the information is for personal use or other specified purposes. This authorization expires on the date or event specified, or one year from the date signed if no expiration date is provided. When I request a copy of my PHI for personal use, federal law permits a reasonable, cost-based fee that includes only labor for copying the PHI, costs for supplies, labor for creating a summary/explanation of the PHI if requested, and postage. If these charges are expected to exceed $25, the practice will attempt to inform me prior to my request being filled. THIS FORM MUST BE FULLY COMPLETED BEFORE SIGNING; INCOMPLETE FORMS WILL NOT BE PROCESSED.

We are pleased that you have chosen us as your healthcare provider. To avoid any misunderstandings and ensure timely payment for services, it is important that you understand your financial responsibilities with respect to your health care. We require all patients to sign our Authorization and Consent To Treatment Form before receiving medical services. That form confirms that you understand that the healthcare services provided are necessary and appropriate and explains your financial responsibility with respect to services received as set forth in this policy.

Patients or their legal representative are ultimately responsible for all charges for services provided. Payment is expected at the time of your visit for all charges owed for that visit as well as any prior balance. Co-pays, deductibles, and co-insurance costs are due at the time of service, and it is your responsibility to understand the limitations of your insurance policy.

We may add a finance charge of 1.33% of your outstanding account balance every month if you do not pay your account in full. If you have an outstanding balance for more than ninety (90) days, you may be referred to an outside collection agency and charged a collection fee of 23% of the balance owed, or whatever amount is permitted by applicable state law, in addition to the balance owed.

If you miss your appointment or cancel with less than 24 hours notice, you may be charged a $195.00 fee for a routine appointment or a missed consultation/evaluation. This fee cannot be billed to insurance and must be paid before you are allowed to schedule another appointment. If you requested interpreter or translation services and miss your appointment without cancelling at least forty-eight (48) hours prior, you may be charged the amount the translation/interpreter service charges our practice for the missed appointment.

The HIPAA Privacy Rule gives me the right to direct how and where my healthcare provider communicates with me. I authorize Boston Brain Center to send secure appointment details, diagnostic notifications, documentation reminders, and secure analytical statements using the communication modalities selected below. I accept full responsibility for any unencrypted digital channels (standard SMS text/unencrypted email) that I choose to authorize for clinical contact. I may update or change these preferences at any time by doing so in writing.

I understand that HIPAA may permit my provider to share my information with other persons not named on this form as needed for my care or treatment or to obtain payment for services provided.

I hereby grant Boston Brain Center explicit permission to utilize secure digital photographic capture and structured video recording parameters acquired during my active therapeutic procedures. These digital metrics are limited strictly to internal clinical documentation tracking, direct execution of motion analysis files, tracking sequences, case presentations, publicity, advertising, and approved secure medical reference frameworks.

I understand there shall be no payment for this release and that no royalty, fee, or other compensation shall become payable to me by reason of such use. I understand I may revoke this authorization at any time by notifying Boston Brain Center in writing; the revocation will not affect any actions taken before receipt of this written notification. Images will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time destroyed or archived.