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About
PT & Training
Shockwave
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PHYSICAL THERAPY CONSENT TO TREATMENT & FINANCIAL POLICIES
Financial Policy: I understand that payment for service is due at the time of service. I am responsible for seeking my own reimbursement from my insurance company, FSA or HSA. I am responsible for understanding the requirements of my insurance, including need for referrals, prescriptions, deductibles and copayments and its limitations. For the initial visit, it is $195. For subsequent visits, it is $150. I agree that Peak Physical Therapy, LLC may discuss my treatment with my physician for the purpose of my care only. It is my right to understand the treatment which I am participating in and I can refuse participation at any time. By initialing and signing this form, I consent to physical therapy treatment.
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INITIAL :
Informed consent for treatment: I understand that I will receive information at the initial visit concerning the evaluation, treatment and options available for my condition. I also acknowledge and understand that I have been referred for evaluation and treatment of orthopedic conditions.
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INITIAL :
Release of medical records: I authorize the release of my medical records to my physician/primary care provider or insurance company. I have reviewed the HIPAA Privacy Rules shown to me by my therapist.
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INITIAL :
Cooperation with treatment: I understand that in order for therapy to be effective, I must come as scheduled unless there are unusual circumstances that prevent me from attending therapy. I agree to cooperate with and carry out the home program assigned to me. If I have difficulty with any part of my treatment program, I will discuss it with my therapist.
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INITIAL :
Cancellation Policy: I understand that if I cancel less than 12 hours in advance, or fail to show up for a scheduled appointment, I will be charged a fee of $150.
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INITIAL :
Graston Technique Informed Consent: All components of the Graston Technique have been explained to me by my therapist. I understand the risks and benefits of the treatment and give my full consent.
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INITIAL :
Print Name and Date of Birth
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Patient/Legal Guardian Signature and Date
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Privacy: I understand that PEAK will strive to maintain my privacy to the highest standards, but I also understand that all electronic transmissions are subject to hacking and malfeasance. I do agree that PEAK may use or disclose my personal health information for the purposes of carrying out my treatment, evaluating the quality of services provided to me, and for administrative operations related to treatment or payment. To help assure privacy, I agree that I will provide PEAK with an e-mail address that only I have access to, that I will use a secure password for that email address, and that I will use multifactor authentication to protect the security of that email address and password. PEAK may utilize the e-mail address I have provided to PEAK for all communications with PEAK including conveying my personal medical information. Release of medical records: I have reviewed the HIPAA Privacy Rules shown to me by PEAK and I authorize the PEAK to release my medical records to my physician/primary care provider and my insurance company. I agree that PEAK may discuss my treatment with my physician for the purpose of my care only. I also agree that PEAK may utilize my medical records in responding to requests for reimbursement. By typing my name below, I am providing my electronic signature acknowledging the above policies (If the patient is less than 18 years of age, the parent or legal guardian must type both their child’s name as well as their name below. By signing below, parents are signing on behalf of their child but are also agreeing that they are personally responsible for the treatment provided to their child under this Agreement.)
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Patient/Legal Guardian Signature
Thank you!
