I understand that in some medical situations, the staff will need to contact local emergency resources before the parent/guardian, child’s physician and or other adult acting on the parent/guardian’s behalf.

Assignment of Insurance Benefits

I understand the confidentiality of my records as protected by law.  Information about me/my child cannot be released without my consent.  I understand I may revoke this consent at any time, and it will automatically expire without my revocation after one (1) year from the date of signature. 

I hereby give authorization for Minnesota Therapy Center to contact and inform my primary and secondary (if applicable) insurance companies of all medical information included in treatment plans relating to all claims for benefits submitted on behalf of myself and/or dependents.  I further expressively agree and acknowledge that my signature on this document authorizes my provider to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claim. I authorize the Insurance Companies named above to pay and hereby assign directly to all benefits, if any, otherwise payable to me for his/her services.  I understand I am financially responsible for all charges incurred.  I further acknowledge that any insurance benefits, when received and paid to MNTC will be credited to my account, in accordance with the above assignment.