FEDERAL WORKER PATIENT AGREEMENT

Our entire staff at Elevated Health NYC is dedicated to helping you get your work-related injury treated and you back to work as soon as possible. There are certain things that we can take care of for you on our end, and certain things that you will have to take care of on your end, in order to get your case approved in a timely manner.

Please review and initial the following statements to show your understanding of our Patient Policies:

I understand I am required to provide this office ALL documentation whether sent to my agency by me or my representative or received from my agency irrespective of whether I believe it to be important or not so it may be reviewed for action items and added to my file.

I understand I am required to provide this office ALL documentation whether sent to OWCP by me or my representative or received from OWCP irrespective of whether I believe it to be important or not so it may be reviewed for action items and added to my file.

I understand my treatment may be terminated, paused or postponed should I not provide all documentation required of me for the acceptance of my case. I will promptly respond to any and all inquiries from my agency and OWCP.

I understand this office bills OWCP directly for my care after the claim has been approved by OWCP. The issuing of a claim number does not mean or indicate your claim has been accepted by OWCP. Should I not provide documentation to this office which is required for approval (employee statements/narrative, factual data, information requests, imaging and diagnostic information, denial letters, reconsideration request forms, appeal forms etc.) or timely processing of my claim that I will be personally liable for any and all fees associated with my care. I understand I simply need to provide all requested documentation or information in order to not be personally liable for any and all fees.

I understand it is my responsibility to call OWCP to verify the receipt of documentation, case status updates and at the request of the staff.

I understand that while this office will help in assisting me with my claim and provide claim management it is ultimately my responsibility to provide my agency and OWCP with requested information and documentation. I will provide my agency with all CA-17 Duty Status Reports and all supporting documentation when submitting claims for compensation by use of form CA-7 and CA-7a. I further understand that all information provided to me as claim management is not legal advice and does not replace the advice of an attorney.

Please sign below to indicate that you have read the above and agree to our office policies:

First Name

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Last Name

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Date

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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