Evaluation and Plan of Care

A: Notifier: Low Vision Works of Florida, LLC  OTR Name*   
B: Patient Name:   {patientName}   
C. Identification Number: {clientDob}     

NOTE:  If Medicare doesn’t pay for D. OCCUPATIONAL THERAPY DONE IN THE HOME below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need.  We expect Medicare may not pay for the D.OCCUPATIONAL THERAPY DONE IN THE HOME below.

D. OCCUPATIONAL THERAPY DONE IN THE HOME
E. Reason Medicare May Not Pay: HOME HEALTH CARE EPISODE OR ANY OTHER REASON MEDICARE WOULD DENY 
F. Estimated Cost: TO BE DETERMINED AT EACH VISIT

·      Read this notice, so you can make an informed decision about your care.
·      Ask us any questions that you may have after you finish reading.
·      Choose an option below about whether to receive the D. OCCUPATIONAL THERAPY DONE IN THE HOME listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

G: Options: Check only one. We cannot choose a box for you.

OPTION 1. I want the D. OCCUPATIONAL THERAPY DONE IN THE HOME listed above. You may ask to be paid now, but I also want Medicare billed for an officialdecision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.    OPTION 2. I want the D. OCCUPATIONAL THERAPY DONE IN THE HOME listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.    OPTION 3. I don’t want the D. OCCUPATIONAL THERAPY DONE IN THE HOME listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.*   

H. Additional Information: This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy.
Signature      Date   
Auth. Rep. Signature   Date   Relationship of authorized representative:   Relationship   
Witness Signature       Date   

CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. Thevalid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (Exp. 06/30/2023)

Form Approved OMB No. 0938-0566

ASSIGNMENT AND RELEASE
I, the undersigned, have insurance coverage with OTR Name* (NAME OF INSURANCE COMPANY) and assign directly to Low Vision Works of Florida, LLC all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the facility to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions. fields and text.

CANCELLATION POLICY
Low Vision Works of Florida must be informed of all cancellations 24 hours prior to the scheduled appointment or as soon as possible. We have a phone system that allows you to leave detailed messages for your therapist or the office staff. Failure to contact LVWS 24 hours prior to time of appointment will result in a $50.00 charge for that treatment time, payable within 30 days.

MEDICARE AUTHORIZATION
I request that payment of authorized Medicare benefits be made either to me or Low Vision Works of Florida, LLC for any services furnished me by that facility. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to
determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated in Item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted forms, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician, or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.

CONSENT TO RELEASE MEDICAL RECORDS
I hereby authorize all physicians, hospitals, nursing homes, clinics and other healthcare providers to release medical information from my records to Low Vision Works. I hereby authorize the release of any medical information from my records to any licensed institutions or agencies by Low Vision Works of Florida, LLC for the purpose of providing continuity of care. I place no limitations on history of illness or diagnostic/therapeutic information including any treatment for substance abuse, psychiatric disorders or acquired immune deficiency syndrome.

CONSENT TO TREATMENT FORM
FREEDOM OF CHOICE
I have independently chosen, with the approval of my physician, chosen Low Vision Works of Florida, LLC as provider of rehabilitation services beginning with the date first above written and until such time as (i) I personally terminate all treatments in progress; (ii) I no longer meet the pay or source criteria (i.e.- my insurance company will not pay for my treatments); or (iii) I am discharged as a patient.

CONSENT TO RECEIVE SERVICES
I authorize the above-named facility to render appropriate rehabilitation services as prescribed by my physician, or by any other physician who may be treating me. I understand that such services may include diagnostic, therapeutic and physical capacity and measurement activities. I confirm that my physician has described and discussed the benefits, risks, consequences and possible alternative treatments of receiving therapy. I hereby affirm that I have disclosed all necessary medical history information to the above-named facility and I am unaware of any physical or mental limitations which may interfere with my receiving the required treatment(s) or adversely affect my health by receiving such prescribed treatments.

I also certify that no guarantee or assurance has been made as to the results that may be obtained.

I HEREBY CERTIFY THAT I HAVE READ ALL OF THE ABOVE CONSENTS, CONDITIONS, AND WAIVERS, THAT I FULLY UNDERSTAND THE ABOVE LANGUAGE, AND AGREE TO BE BOUND BY THE TERMS OF SUCH PROVISIONS. I FURTHER CONFIRM THAT ANY AND ALL QUESTIONS AND CONCERNS THAT I MAY HAVE HAD HAVE BEEN ANSWERED TO MY SATISFACTION.

Can the patient sign for him/herself?
Yes    No*