Consent Form

Informed Consent Form

You have consulted with On Point Movement & Performance, DBA, and I have decided to receive therapy services. It is important that you, the client, read this consent form carefully and obtain answers to any questions that you may
have.

Physical and Occupational Therapy: PT/OT Therapy involves several methods of evaluation and treatment. We use a variety of procedures and treatments to help us try and improve your physical and psychosocial function. As with all forms of medical treatment, there are benefits and risks involved. Patient responses to a specific form of treatment can vary widely from patient to patient, and it is not always possible to predict responses to a given form of treatment. There is a risk that your treatment may result in pain, injury, or aggravation of a previous condition.

Wellness: Wellness services will include methods of screening and exercises. As with all forms of exercise, there are benefits and risks involved. Patient responses to a specific form of exercise can vary widely from client to client, and it is not always possible to predict responses to a given form of treatment. There is a risk that your treatment may result in pain, injury, or aggravation of a previous condition

Speech Therapy: Speech involves several methods of evaluation and treatment. We use a variety of procedures and treatments to help us try and improve your function. As with all forms of medical treatment, there are benefits and risks
involved. Patient responses to a specific form of treatment can vary widely from patient to patient, and it is not always possible to predict responses to a given form of treatment. There is a risk that your treatment may result in pain, injury, or
aggravation of a previous condition.

You have the right to inquire as to the form of treatment based on your history, diagnosis, and symptoms.

You may discuss the potential risks, and benefits of specific treatment with your provider, and possible alternative treatments.

You have the right to decline treatment at any time or during your treatment sessions.

Your therapist will answer questions you may have regarding a given course of treatment, type of exercise or treatment method, associated risks, and possible alternatives.

This consent form is based upon your informed decision to participate in the proposed treatment plan for therapy services. It has been discussed with me in words that I can understand, my diagnosis, conditions, reasons for and benefits of the plan of care, the reasonable likelihood of success, the possible material risks of not following the plan of care, the possible risks associated with the plan of care, and possible alternatives and risks associated with those alternatives. I have discussed my goals of recovery and potential problems that might arise during treatment. I have decided not to participate in alternative treatments at this time. I understand there are risks associated with therapy as described above. I am giving this consent with the understanding that any treatment or services involve some risks and hazards, and that no guarantees have been made to me.

I acknowledge that services may be provided to me by another therapist other than those identified on this form.

I HEREBY CERTIFY THAT I HAVE READ THIS FORM (OR HAVE HAD IT READ TO ME) AND FULLY UNDERSTAND THE ABOVE CONSENT. I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND ALL OF MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. I DO NOT DESIRE ANY FURTHER EXPLANATION AND UNDERSTAND AND ACKNOWLEDGE THAT COMPLICATIONS CAN RESULT.

Cancellation Policy

I understand cancellations should be made 24 hours in advance. If not a $50 cancellation fee will be billed to the card on file.

Notice of Privacy Practices (available on https://www.onpointmvp.com/notice-of-privacy-practices.html)

I acknowledge receipt of the Notice of Privacy Practices from On Point Movement & Performance, DBA. I understand that the Notice of Privacy Practices provides information about how On Point Movement & Performance, DBA may use and disclose my protected health information. I have reviewed it and understand that the Notice of Privacy Practices is subject to change. If the Notice is changed, I may request a revised copy.

Consent for Treatment
I hereby consent to such treatment procedures and patient care which, in the judgment of my therapist and/or physician, may be considered necessary or advisable while I am a patient of On Point Movement & Performance, DBA.

Guarantee of Account

I hereby guarantee payment for any services rendered to me which are not covered or allowable by Medicare, together with collection costs, including reasonable attorney fees. I also understand that all bills are due and payable upon presentation. I understand that the client’s responsibility portion of my bill shall
be due and payable at the time of services. I understand that I am personally responsible for full payment of all charges including Medicare denials, deductibles, and copayment fees. I understand that On Point Movement & Performance, DBA does not submit to any other insurances, unless negotiated before the start of service. I understand that I will be provided with an invoice for services not covered by Medicare which I can submit to my own insurance for reimbursement. in consideration of services rendered to me by On Point Movement & Performance, DBA

Medicare/Insurance
I hereby certify that my information in applying for payment under title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any such information needed for this or a related Medicare/Insurance Claim. I request that the payment of authorized benefits be made on my behalf. I understand that I am responsible for any health insurance deductibles and co-insurance. I understand that I cannot receive Medicare Part B services in the home if I am currently on Home Health under Medicare Part A and or on Hospice Care. I understand that services must be skilled and medically necessary to be covered by Medicare Part B. I understand Medicare will pay for 80% of the allowed amount, and I am responsible for the remaining 20% (Good Faith Estimate is $20-$30 per visit) if I do not have secondary insurance or if my secondary insurance does not cover the 20% due to policy limitations. Insurance Good Faith estimate: not to exceed more than $250 per visit.

 

Home Health

While under medicare part B, I understand that I can not be receiving home health/hospice or hospital services as a medicare part A service and will be financially responsible if I have not confirmed that I have been discharged from home health services.

Release of Information
I hereby authorize the release of any information by telephone, email/fax, or in writing, including reports of diagnosis, treatment prognosis, recommendation, as well as any other data pertinent to my treatment, by On Point Movement & Performance, DBA to the physician who referred me for therapy. I also authorize the release of any information by telephone or in writing for utilization and quality review purposes.