Patient Rights and Responsibilities
I have read and received a copy of this information sheet & patient rights & responsibility sheet. I authorize payment of medical benefits to this provider. I give this provider permission to make any necessary complaints on my behalf to expedite payments. A treatment plan will be discussed with me & I consent to care per the plan. My co pay & estimated co-insurance amounts will be due at each date of service & I am ultimately responsible for my bill. If I receive payment for my therapy, I will endorse those checks & forward them directly to the clinic. If I cash the checks OR do not pay per visit (if applicable) leaving a balance due and pay the clinic by credit card, a 5% fee will be paid by me. I also understand that a finance charge of 1.5% monthly (18% annual percentage rate) will be added to my outstanding account balance after 30 days. Late fees, interest charges and credit card swipe charges do not apply to Medicare/Medicaid beneficiaries.
CALL YOUR INSURANCE AND VERIFY YOUR PHYSICAL THERAPY BENEFITS. WE DO SO AS A COURTESY AND CANNOT GUARANTEE WHETHER OR NOT YOUR INSURANCE WILL PROCESS DIFFERENTLY.
I agree to and understand all statements above. I will pay all cost of collection fees and court fees associated with non payment of any amount owed and assignment to collection agency.
CONSENT FOR TREATMENT
Authorization/Disclosure of information/consent to treatment form
Body Image Physical Therapy (BIPT) understands the importance of privacy. We are continuing to address compliance with federal HIPAA laws. It is important as patient that you are aware that BIPT is doing everything to maintain your privacy.
We will continue to work together with all of the professionals involved in your care to ensure you receive the highest quality treatment possible. This may entail verbal and written correspondence with your physician’s office as we update them on your progress. It may mean exchanging information with your insurance company, attorney offices, or in the case of Worker’s Comp, your employer. Should you require durable medical equipment or supplies, it may also mean giving information to medical supply distributors and/or 3rd party payers.
In the event that your primary physical therapist is absent, another qualified physical therapist will be responsible to treat your condition. Your information will be given only to that individual who has temporarily or permanently taken over your care.
Should any questions arise during the course of your treatment at BIPT you should speak with your treating therapist. By signing this form you are considering to care as outlined in your initial evaluation and in subsequent notes by your physical therapist. Every effort will be made to explain treatment procedure to you to ensure that you understand why the treatment is necessary.
If you have any questions about charges, billing procedures, your benefits or your statement beyond what has been explained to you by the clinic staff, you may call our billing department at 1-866-679- 1600 ext 324.
Informed consent and waiver of liability for personal fitness training and general use of the equipment
I expressly agree that all use of the combined Body Image Physical Therapy and Saddle Rock Fitness (hereafter, SRF) facility shall be undertaken by me at my own risk, whether I am engaging in an individual exercise session with a trainer or whether I am engaging in any unsupervised training session recommended or suggested by the trainer or other qualified staff members.
Further, I understand that training sessions will require physical exertion, such as aerobic activity and resistance training. I recognize that exercise is not without some risk to the musculoskeletal system (may include: sprains, strains) and cardio-respiratory system (may include: dizziness, fainting, abnormal heartbeat, discomfort on breathing, abnormal blood pressure response and in rare cases, heart attack, stroke or death). I hereby acknowledge and accept these risks.
In signing this statement, I am aware of any physical or mental limitations, which would preclude me from participation in classes or training sessions. I understand that should I have a history of heart disease or cardiorespiratory complications or if I am currently taking medications for these conditions that I may not proceed with a training program without first obtaining written consent from my physician.
I understand that SRF shall not be liable for any injuries for damages to me or my property, and that SRF shall not be subject to any claim or demand for injuries of damages which result, either directly or indirectly, from my participation in a training session or a class, or by any use by me of the SRF equipment in any supervised or unsupervised training session. It is my understanding that staff trainers may not carry their own liability insurance, and that qualification of staff trainers are on file with SRF and are available for inspection at any time.
I, for myself, and on behalf of my executors, administrators, and successors in interest do hereby expressly forever release and discharge SRF it’s successors in interest and assigns, as well as its officers, directors, agents, and owners, for all such claims or demands for injuries or damage, resulting from my participation in any training session or class, both supervised or unsupervised, or any training session or class which has been recommended by the staff of SRF.
I acknowledge that I have entered into an agreement with Body Image Physical Therapy and Saddle Rock Fitness, to participate in supervised and unsupervised training sessions and/or classes by qualified personnel.