I, the patient, (or for the
patient), do hereby voluntarily consent to such care encompassing diagnostic procedures and
treatment as ordered by the prescribing physician, his/her assistant(s), consultant(s), as is necessary in
his/her professional judgment. I assume responsibility for discussing and understanding my proposed
and goals based on the evaluation with my practitioner, as well as expected benefits and potential risks
drawbacks of the evaluation and service, and understand treatment does not guarantee an improvement in
patient’s current condition.
I hereby authorize Viverant, its employees or agents, to release medical information regarding myself and my
current condition(s) to my insurance company for purposes of payment and/or quality reviews; and referring,
consulting, treating physicians, or other medical providers as necessary to support continuity of care.
authorization will remain valid until mutually revoked in writing by both the
patient and Viverant. I understand that Viverant has made a copy of their Notice of Privacy
Practices available for my review, and that I can request a copy at anytime in writing or by contacting a
Viverant office representative. I give Viverant consent to utilize photos, videos, and/or written/verbal
testimonials for marketing purposes, and authorize Viverant to utilize my contact information, such as
addresses or phone numbers, to correspond with me information not considered Protected Health Information
I, the patient, (or ________________
for the patient), understand I am responsible for communication with my
insurance company regarding any co-payments, deductibles, or provider information pertaining to my
Viverant. I understand that I am responsible for obtaining any required referrals from primary care
understand I am ultimately responsible for any charges not covered by third party payers. I attest that I
not currently receiving or enrolled in home health services. I agree to notify Viverant in writing if I
home health services, and acknowledge that failure to notify Viverant in writing will result in my being
financially responsible for services rendered, up to $160 per visit. I have reviewed the various
scenarios and understand that I am responsible for all outstanding balances. I also understand that, any
balance on my account over 60 days outstanding, after insurance has processed said claim(s), is subject to
interest fee per month; any account 90 days outstanding, or in collections for non-payment, will assess a
processing fee and will require payment in full prior to further treatment. Any patient payments returned
insufficient funds will be assessed a $20 NSF fee. In addition, I understand that I am responsible for any
equipment or supplies purchased specifically for my treatment, and I will be billed for any such supplies
$10.00 in value. I also understand if I schedule and fail to show for an appointment, or fail to
business day notice of my cancellation, Viverant may charge me a No-Show fee of $50 and any
translation/interpreter charges incurred due to lack of notice, and after 2 occurrences may result in
appointment scheduling restriction to same-day scheduling only.
I understand that if I choose Viverant's Self-Pay payment option, I agree NOT to solicit reimbursement
any third party payer for Self-Pay services received at Viverant. I understand each individual Self-Pay
treatment purchased must be redeemed within 12 months of purchase before expiration. I also understand if I
choose not to utilize self-pay, Viverant is not able to withdraw claims already submitted to my insurance.
select Viverant's self-pay services, I understand Viverant is NOT able to withdraw claims already
to my insurance to switch to self-pay, and is NOT able to reprocess self-pay claims to insurance.
I agree I am responsible for notifying Viverant within 30 days of change in insurance coverage, or
of existing coverage. If I fail to do so within that timeframe, I will be responsible for full balance due
services rendered. If I notify Viverant of new insurance after services have already been rendered, and
insurance will not cover services due to plan-level requirements not being met (such as but not limited to
Orders, Prior Authorization), I agree to be responsible for full balance due of services rendered.
I hereby agree that I, my assignees, heirs, distributees, guardians, and legal representatives will not make
claim against, sue, or attach the property of Viverant or any agent of Viverant on account of injury or
resulting from the negligence or other acts, howsoever caused, by any employee, agent, or contractor of
Viverant. I hereby release Viverant from all actions, claims, or demands that I, my assignees, heirs,
distributees, guardians, and legal representatives now have or may hereafter have for injury or damage
resulting from my treatment at Viverant.
If applicable, I authorize third party payment directly to Viverant of the benefits otherwise payable to me.
Those charges are not to exceed the regular charges for this period of treatment. If I have sought
due to my injury and refuse to provide the appropriate insurance information, I understand that I am
to pay Viverant at the time services are provided. I also understand that if I have filed a Workers
Compensation claim and my claim is denied, I will then be responsible for payment of services as they are
received if I do not provide health insurance. I understand I am financially responsible to Viverant for
charges not covered by this authorization.
* I have read this form
certify that I understand and agree to all terms and conditions.
* I have read a copy of
Viverant Privacy Practices Statement (or waive my right to read this document) and understand my
rights as they pertain to my treatment at Viverant.
Contact us today to get started.
877-609-0123 or 952-835-4512