Provider: Mobile Rehab LLC | 229 Fearrington Post, Pittsboro, NC | 919-636-2423

1. Informed Consent & Risks: I authorize Mobile Rehab to provide physical therapy services. I understand the goal is to improve function, but that risks exist, including soreness, muscle/ligament strain, fractures, or fainting. I will notify my therapist immediately of any worsening symptoms or distress. I agree to provide a safe, hazard-free environment for mobile treatment sessions.
2. Cancellation & No-Show Policy: I agree to provide 24 hours’ notice for cancellations. Failure to do so results in a $35.00 fee, which is my personal responsibility and cannot be billed to insurance.
3. Communication & Electronic Disclosure: I authorize communication via email and text for scheduling, clinical updates, and billing. I accept the privacy risks of these non-secure channels. I received or was provided access to the Notice of Privacy Practices (NPP) and authorize the release of medical information to my physicians and insurance for treatment and billing.
   Access NPP at https://mobilerehabnc.com/notice-of-privacy-practices/
4. Legal Representation & Guardianship: If signing as a representative, I certify that I have the legal authority (such as Power of Attorney or Guardianship) to consent to treatment on the patient's behalf.
5. Reimbursement Coverage & Financial Responsibility: I assign all insurance benefits to Mobile Rehab LLC and authorize them to act on my behalf during appeals. I am financially responsible for any portion not covered by insurance, including deductibles and co-insurance.

This agreement remains in effect until terminated in writing.