Consent for Physical Therapy Treatment and
Authorization for Release of Information
Consent for Physical Therapy: I hereby voluntarily consent to the rendering of care for a condition or conditions requiring physical therapy services. I understand that diagnosis and treatment may involve risks or injury. I acknowledge that no guarantees have been made to me as a result of examination or treatment.
Consent for Blood Testing: I give my permission for a sampling of my blood to be tested for infectious disease in the event that a therapist or other employee becomes exposed to my blood or bodily fluid.
Authorization for Release of Information: I authorize my referring physician to release any information necessary for my evaluation and treatment at Pivotal Physical Therapy.
Payment of Services: I authorize any release of medical information that is required for payment owed by me to Pivotal Physical Therapy. I agree that Pivotal Physical Therapy will not be responsible for confidentiality of any documents released to any insurance carrier or other entity responsible for payment of my health care costs. I authorize payment from any payer to be made directly to Pivotal Physical Therapy/Terry Rhoades.
I understand that I am financially responsible to pay all costs and fees to Pivotal Physical Therapy that are not covered by my insurance company/companies. I agree to pay collection costs including attorney fees incurred by Pivotal Physical Therapy related to collecting costs and fees charged to me for all services rendered and goods provided in the event of failure to pay all debts.
Cancellation / No Show: Pivotal Physical Therapy is committed to provide the best service possible to every client. I understand that I must give at least 24 hours cancellation notice if I am unable to keep my scheduled appointment, so that Pivotal Physical Therapy may notify other patients who may need treatment. If unable to provide this notice, I agree to pay a $30 cancellation fee at my next appointment.