*Please note, OC Sports & Rehab utilizes electronic statements. You must provide an active mobile phone number and email address.

CANCELLATION POLICY: We Understand life happens and circumstances can arise, but please allow others to use your spot by giving us 12 hours advanced notice of appointment cancellations. Any NO SHOWS or same day cancels will be assessed a $25 fee.

By checking this box and entering my initials in the field below, I confirm that I have read, understood, and agree to the terms, conditions, and policies outlined above. I acknowledge that this action constitutes my electronic signature and carries the same legal weight and enforceability as a handwritten signature.

FINANCIAL POLICY: I hereby agree to pay my account AS SERVICES ARE PROVIDED. Deductibles, co-pays, and co-insurances will be collected for at the time of service. If for any reason there is a balance on my account, I agree to pay it promptly.

OC Sports & Rehab cannot assume responsibility for incorrect information provided to us concerning your insurance policy. Our courtesy verification of eligibility and benefits does not guarantee that your insurance company will pay for all services provided. Your insurance policy is a contract between you and your insurance company. You are responsible for knowing your level of coverage and are ultimately responsible for the full payment of your bill.

Being referred to our clinic by a physician does not necessarily guarantee that your insurance will cover our services, that we are a contracted provider with your plan, or that we accept the same plans and carriers that your referring physician does. Please remember that you are 100% responsible for all charges incurred: your physicians’ referrals, prescriptions, and our verification of your insurance benefits are not a guarantee of payment.

OC SPORTS & REHAB REQUIRES PATIENTS TO HAVE A CREDIT OR DEBIT CARD ON FILE TO SCHEDULE FOLLOW-UP VISITS.
ALL PATIENTS ARE REQUIRED TO HAVE A CARD ON FILE REGARDLESS OF INSURANCE OR VISIT TYPE. *

*This does not apply to patients being seen under their Worker’s Comp policy as long as the visits are authorized by the insurance company.

OC Sports & Rehab will use the debit/credit card on file to process transactions for in-office payments and for past due, outstanding balances not paid timely. For more information regarding our credit card on file policy, please refer to our credit card authorization form.

By checking this box and entering my initials in the field below, I confirm that I have read, understood, and agree to the terms, conditions, and policies outlined above. I acknowledge that this action constitutes my electronic signature and carries the same legal weight and enforceability as a handwritten signature.

ASSIGNMENT OF BENEFITS & RELEASE OF INFORMATION: I hereby authorize and assign my therapy insurance benefits to be paid directly to OC Sports & Rehab. I also authorize OC Sports & Rehab to release any necessary medical information to process my claims. By signing below, I authenticate that authorization for assignment of benefits and release of information by providers at OC Sports & Rehab.

By checking this box and entering my initials in the field below, I confirm that I have read, understood, and agree to the terms, conditions, and policies outlined above. I acknowledge that this action constitutes my electronic signature and carries the same legal weight and enforceability as a handwritten signature.

CONSENT TO TREATMENT & THERAPEUTIC PROCEDURES: I hereby consent to the therapeutic procedures outlined below, to be performed by OC Sports & Rehab and their associates:

• I agree to be evaluated and treated for functional loss due to related nerve, muscle, and skeletal dysfunctions and/or pain.
• I understand that therapeutic procedures can include, but are not limited to: joint and soft tissue mobilization, home exercise programs, functional training for posture and body mechanics, modalities, such as heat, ice, electrical stimulation, and ultrasound, and special procedures such as: taping and neuromuscular electrical stimulation.
• I understand that I will be explained the purpose of the therapeutic procedures prior to receiving treatment and that I may refuse any therapeutic procedure or treatment at any time.
• I understand that I may consult with other therapists and/or physicians at any time regarding my conditions.
• I understand that no guarantee of a successful outcome has been given to me.
• I understand to inform my therapist of any changes in my condition at any time during my care.
• I certify that I have read and understand the above consent statements:

By checking this box and entering my initials in the field below, I confirm that I have read, understood, and agree to the terms, conditions, and policies outlined above. I acknowledge that this action constitutes my electronic signature and carries the same legal weight and enforceability as a handwritten signature.

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES: I acknowledge I have self access to the Notice of Privacy Practices, and that I can read, if I so choose, and I understand the notice that is posted online. The Notice of Privacy Practice is available any time on our website at www.ocsportsandrehab.com. Our team is happy to help you find the link on our website or print a copy for you if you ask.

By checking this box and entering my initials in the field below, I confirm that I have read, understood, and agree to the terms, conditions, and policies outlined above. I acknowledge that this action constitutes my electronic signature and carries the same legal weight and enforceability as a handwritten signature.

Credit Card on File Policy & Authorization Form

As of December 1st, 2024, OC Sports & Rehab requires all patients to have a credit or debit card on file to schedule follow-up visits. We process payments through a HIPAA-compliant, secure practice management software. Upon arrival to your first appointment, we will request a debit or credit card to save to your profile. Your payment information is encrypted and stored on our EMR’s secure servers for future transactions. Office personnel do not and will not have access to your card data. To avoid any issues of discrimination or favoritism, all patients will be required to have a debit or credit card on file, regardless of insurance or visit type. OC Sports & Rehab does not accept cash or checks for payments made in-office or for outstanding balances following receipt of a statement.

Credit Card on File will be used to process payments for:

• Deductibles, co-pays, and/or co-insurances deemed to be the patient’s responsibility at the time of service.
• Account balances after insurance adjudication/claims processing.
• Appointment no-shows/late cancellation fees.
  
  

OC Sports & Rehab utilizes electronic statements. All patients must have a valid email address and active mobile phone number on file. We do not send paper statements via mail. OC Sports & Rehab is not responsible for inaccurate or outdated phone/email information provided to our office that results in unreceived electronic statements. We advise all patients to promptly notify us of any changes in contact information.

If for any reason there is a balance owed on your account, you will receive an electronic billing statement outlining the dates of service owed for, and insurance vs. patient responsibility amounts. If any payments were collected at the time of service, they will be applied accordingly. You may still receive a statement for a small difference if your patient responsibility is more than what was collected in-office. Upon receipt of your billing statement, OC Sports & Rehab allows seven (7) calendar days for payment to be remitted. Payments can be made in-person at any of our locations, online through the bill pay portal on our website, or by calling and providing payment information over the phone.

Our Card on File Policy in no way negates the ability for billing-related questions to be brought forth and discussed with our billing department. If there are any questions or discrepancies regarding your bill, please contact us as soon as possible so that we may review and address your concerns in a timely manner, before your account is past due. If your balance is not paid within 7 days, and if no formal concern is raised to our billing department, OC Sports & Rehab will use the credit or debit card on file to pay your outstanding balance and bring your account current. This notice is outlined on our billing statements and through electronic correspondence to ensure ample notifications are provided to each patient. Should this type of transaction take place, our EMR will email you a receipt automatically, notifying you the payment was processed.

OC Sports & Rehab does not allow patients to carry balances on their account while actively being seen. During the check-in process, if there is a balance on your account, you will be notified of the amount by the front desk, and it will be collected for at the time of service, using the debit or credit card on file. Balances must be paid to continue scheduling appointments. By collecting balances regularly and not allowing accounts to balloon out of control over weeks or months of care, we also hope to noticeably improve the transparency of the billing cycle and mitigate the potential of patients getting large, unexpected bills from our practice down the road.

Nothing is changing about how much you pay. When you come into our office and receive a service, you do so with the understanding that you are ultimately responsible for the cost of your care. We bill your insurance company for you, and we have contracts with most insurance companies that help to get you the best possible coverage for your care. You are still only responsible for the portion your insurance company deems to be yours, as indicated on your EOBs following claims processing. If your insurance company covers 100% of the cost of your treatment (often the case in patients with Medicare + Supplements, or patients who have met their annual out-of-pocket maximums), your patient responsibility for each visit would be $0, and there would be no balance to collect from you, and no charges made to your card on file. However, in recent years, we have found that even patients with dual coverage often aren’t covered entirely at 100%, and out-of-pocket maximums are seemingly getting more and more out of reach, resulting in the vast majority of patients having some degree of cost associated with their care.

Should you have any further questions regarding our Credit Card on File Policy, please do not hesitate to ask us. By signing below, you:

• Acknowledge receipt and understanding of the information and policy outlined above.
• Authorize OC Sports & Rehab to save your debit or credit card to your account.
• Authorize use of card on file for in-office/time-of-service payments (deductibles, co-pays, co-insurances, and balances newly posted to account between regular visits) and for past-due balances not paid timely within 7 days of receipt of a statement.

By checking this box and entering my initials in the field below, I confirm that I have read, understood, and agree to the terms, conditions, and policies outlined above. I acknowledge that this action constitutes my electronic signature and carries the same legal weight and enforceability as a handwritten signature.

HEALTH CARE PROVIDER-PATIENT ARBITRATION AGREEMENT

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by a submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the health care provider including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the healthcare provider, and the health care provider’s partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the health care provider or patient to collect or contest any medical fee shall not waive the right to compel arbitration of any malpractice claim. However, in following the assertion of any malpractice claim, any fee dispute, whether or not the subject of an existing court action, shall also be resolved by arbitration.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such a party’s own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.

The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.23. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05; however, depositions may be taken without prior approval of the neutral arbitrator.

Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature. It is the intent of this agreement to apply all medical services rendered any time for any condition.

Article 6: Retroactive Effect: If the patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:

Effective as of the date of first medical services.

If any provision to this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBIRTARTION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

By checking this box and entering my initials in the field below, I confirm that I have read, understood, and agree to the terms, conditions, and policies outlined above. I acknowledge that this action constitutes my electronic signature and carries the same legal weight and enforceability as a handwritten signature.