Welcome and thank you for choosing Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC for your physical therapy and wellness needs.
Florida Law and the State of Florida Physical Therapy Board does not require patients to have a written Referral for Physical Therapy for an initial evaluation and up to 30 days of treatment by a physical therapist. However, patients are required, after 30 days, to obtain a written Referral for Physical Therapy from a licensed medical person (MD, DO, DC, DDS, DPM, ANP, PA). It is your responsibility to obtain and maintain a current referral after 30 days of treatment.
Purpose and Explanation of Service
Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC provides strength training services and recovery/ physical therapy services. I understand that the purpose of the exercise/strength training program is to develop and maintain cardio-respiratory fitness, body composition, flexibility, muscular strength and endurance. A specific training plan will be given to me, based on my needs and abilities. The programs include, but are not limited to aerobic exercise, flexibility training, and strength training. All programs are designed by certified strength coaches to place a gradually increasing workload on the body in order to improve overall fitness. I understand that the purpose of recovery/physical therapy services can include the use of hands-on or instrument assisted soft tissue techniques, corrective exercises, active release techniques, dry needling, and/or other techniques performed by a license and state certified athletic trainer or physical therapist, based on my specific needs or diagnosis.
Physical activity by its very nature carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injury. Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC provides services for interested parties involving strenuous muscular exertions that carry risks ranging from 1) minor injuries such as scratches, sprains, and bruises to 2) major injuries such as joint or back injuries, concussions, and heart attacks to 3) catastrophic injuries including paralysis and/or death.
I, on behalf of my heirs, personal representatives, do hereby release, waive, discharge, and covenant not to sue claims arising from the negligence ofOld Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC and its directors, officers, employees, volunteers, independent contractors from liability for any and all claims arising from any of the aforementioned parties. This agreement applies to 1) Personal injury from accidents or illnesses arising from the observation and/or participation in activities including strength training, recovery services, therapy services, fitness and yoga classes taught on premises and individual use of facilities or equipment; and 2) any and all claims resulting from the damage, loss, or theft of property.
I have read the previous paragraphs and I know the nature of the activities of Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC and understand the demands such activities present for my physical condition and my skill level. I hereby assert that my participation is voluntary and that I knowingly assume all such risks. I expressly agree that this waiver and assumption of risks agreement is intended to be as broad and inclusive as permitted by the laws of the State of Florida and intended for my signature to be a complete and unconditional release of all liability to the greatest extent allowed by the law in the State of Florida.
Confidentiality and Use of Information
I have been informed that the information obtained in this exercise program will be treated as privileged and confidential and will consequently not be released or revealed to any person without my express written consent. Any other information obtained, however, will be used only by the program staff to evaluate my exercise status as needed.
Privacy Rights: You have a right to privacy under the Health Insurance Portability and Accountability Act (HIPAA) that includes restricting disclosure of your records and claims to your health plan, including Medicare, if you pay privately for your services at the time of service. By paying for your services at the time of service, we assume you are exercising this right to privacy and we will not disclose your medical records to any third party, including your health insurance carrier or Medicare. If you want your records disclosed to any third party in the future, you will need to obtain and sign our Disclosure to Release Protected Health Information form before we will disclose your health information.
Inquiries and Freedom of Consent
I have been given an opportunity to ask questions about the training program. Despite the fact that a complete accounting of all these remote risks has not been provided to me, I still desire to proceed with the exercise program.
I acknowledge that if I must cancel out of a training or therapy session, I will give my trainer or therapist at least 12 hours’ notice, and that if I cancel within the 12-hour time period of the start time of the session, I will be charged for that session. I understand that due to circumstances that may be beyond my control, I will receive one free “no show” every three months of training, meaning that I may late cancel once within a three month period and not be penalized. All sales for personal training, recovery or therapy sessions are final and nonrefundable. Personal training, recovery, or massage sessions are valid from six months from the original purchase date and are transferable from one person to another.
I acknowledge that I have read this document in its entirety or that it has been read to me if I have been unable to read the same. I consent to the rendition of all services and procedures as explained herein by all program personnel.
Consent to Treatment
Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC is a movement-based and hands-on Physical Therapy clinic. Treatment consists of manual therapy techniques and treatment forms that are published or otherwise publicly known, as well as highly specialized therapeutic exercise, neuromuscular re-education, bone and soft tissue manipulation, dry needling, myofascial release, and other treatment modalities may be used.
Some of the hands-on treatment techniques require deep pressure which may cause bruising and periods of increased soreness which may last from 1-72 hours. Symptoms may also change and move to other parts of the body. This is not unusual and is rarely a concern, however, please ask if you have any concerns or questions.
The number of treatments needed and recovery time can vary widely due to the age of injury, number of times injured, age of patient and many other contributing factors.
I have read and fully understand the above statements. I understand the nature of the treatments at Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC and I authorize the fully trained staff to use treatment techniques as deemed necessary for my safe and effective recovery.
Before we begin services, please sign below indicating you have read, understand and agree to the following payment policies.
You agree to be financially responsible for all charges regardless of any applicable insurance or benefit payments, third-party interest, or the resolution of any legal action or lawsuits in which you may be involved.
Direct Pay and Out-of-Network Policy: Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC is a fee-for-service clinic. This means that Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC is not “in-network” with any private health plans. Payment is due at the time of service, regardless of using cash pay or using Out-of-Network Benefits. Depending on your Out-Of-Network plan benefits, you may be reimbursed directly from us or your insurance company for your sessions.
We accept cash, personal checks, and credit cards.
Medicare Policy: If you are a Medicare beneficiary, you understand that our licensed physical therapists are not enrolled as Medicare providers. Medicare has onerous technical and administrative requirements that must be met for services to be considered medically necessary covered benefits. We believe those requirements take unnecessary time away from the services we provide. Since the documentation and administrative processing of our services are not designed to meet Medicare’s covered benefit requirements and we are not Medicare enrolled providers, our services will not be covered (paid) in full or in part, by Medicare (including Medicare Advantage Plans) even if the same services might be considered covered benefits when provided by a Medicare enrolled provider.
We will not submit claims to Medicare on your behalf or provide you with a statement or billing codes that you can submit to Medicare yourself. If you want Medicare to pay for any services that might be considered covered benefits, you should seek those services from a Medicare enrolled provider.
By choosing to receive our services after being fully informed of these facts, you are agreeing, of your own free will, that you do not want Medicare involved in payment for your physical therapy services at Old Bull Athletics, Inc., Old Bull Sports Medicine and Rehabilitation LLC, and Old Bull Athletics 2 LLC. You agree to pay privately for the services you receive from us even if those services might be covered by Medicare if provided by a Medicare enrolled provider.
You also understand that since we are not enrolled Medicare providers and our documentation and administrative processes do not meet the technical requirements for Medicare to cover the services we provide, our services are not subject to Medicare’s maximum allowable charge.
You agree that you, your caregivers, family members, authorized representatives or power of attorney will not, under any circumstance, submit our claims, invoices, receipts, statements, or treatment notes to Medicare, a Medicare Advantage Plan, or to any primary-payer private insurance for reimbursement or to obtain a denial for a Medicare supplemental insurance plan.