Consent for Treatment and Billing of Services Rendered and Acknowledgement of HIPAA Notice of Privacy Practices
Consent for Treatment, Exchange of Information and Billing for Services Rendered by Venture Rehabilitation Group
By signing this consent for medical treatment and billing, I hereby declare the following:
  • I grant permission for a representative of Venture Rehabilitation Group to evaluate and/or treat the above named patient.
  • I authorize payment to be made to Venture Rehabilitation Group for services provided. I authorize Venture Rehabilitation Group to release to my insurance carrier protected health information (PHI) for the purposes of billing for services provided.
  • I give Venture Rehabilitation Group permission to bill Medicaid and/or my third party reimbursement party for charges pertaining to the above named patient for evaluation and treatment. I assume financial responsibility for any balance due including co-pays, co-insurance and balance not paid by my insurance.
  • I give permission for Venture Rehabilitation Group to release and receive information pertaining to my child’s services with the following agencies:

This consent is valid from the date a signature is obtained until date of discharge from Venture Rehabilitation Group.

Acknowledged and agreed to by:
HIPAA Acknowledgement of Receipt of Venture Rehabilitation Group’s Notice of Privacy Practices

By signing this authorization you acknowledge and agree that Venture Rehabilitation Group or its Business Associates may use or disclose the Protected Health Information (PHI) of the above named patient for the purpose of providing treatment, for purposes relating to the payment of services rendered, and for VRG’s general healthcare operations.

By signing below, you are confirming that you have received, reviewed, understand and agree to the Notice of Privacy Practices of VRG regarding the use and disclosure of any of your Protected Health Information created, received or maintained by VRG.