New Patient Paperwork (Insurance)

Informed Consent
I do hereby agree and give my consent for Physical Therapy San Pedro to furnish care and treatment that is considered necessary and proper in diagnosing or treating my physical condition.

I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.

I hereby certify that all the above information is true to the best of my knowledge.
Printed Name*
Signature*

Clear
Date*

MonthDayYear
Date
I understand that Physical Therapy San Pedro will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.

Photographs taken during the duration of treatment will be used for postural comparison purposes and as educational tools. By signing below, I consent to the use of these photographs in a professional manner.
Printed Name
Signature

Clear
Date

MonthDayYear
Date
In addition, photographs and video will be used as educational tools for website and social media purposes. By signing below, I consent to the use of these photographs in this manner.
Printed Name
Signature

Clear
Date

MonthDayYear
Date

Reassignment of Benefits

(Out-of-Network Insurance)
To Whom It May Concern:

I__________________________________________,allow assignment of benefits to be issued to the treating provider,

Dr. Janae Brown, PT, DPT.

I am aware that Physical Therapy San Pedro is a non- participating provider.

If you receive payment made directly to you, please cash these payments and make a payment directly to:

Dr. Ja’nae Brown, PT, DPT

481 W 6th Street San Pedro, CA 90731

*Note: payments can also be made via website phsyicaltherapysanpedro.com

Kindly,
Patient Name*
Policy Holder Name*
Policy Holder Signature*

Clear
ID #
DOB*

MonthDayYear
Date
Date*

MonthDayYear
Date

Cancellation/No-Show Policy

(Insurance Pay)
All cancellations need to be made 24 hours prior to your scheduled appointment.

If you do not show up for your appointment or cancel within 24 hours, you will be responsible to pay for 100% of the session.

To avoid this cancellation fee, your appointment will be automatically adjusted from an in-person to Telehealth.
Telehealth Email*
example@example.com
Payment Policy

Your insurance benefits will be checked and verified prior to your initial treatment and you will be notified of your out of pocket expense. Treatment will be billed under your out of network physical therapy benefits and payment for the difference in coverage based on copayment and coinsurance responsibilities, in the form of cash, check or credit card, is due at the time of each visit. Because Dr. Ja’nae Brown is an out of network provider, your insurance may send payments directly to you, the patient. Please contact our office upon receipt of payment. You will be billed the full amount charged to your insurance company until payment is remitted to Dr. Ja’nae Brown.

I have read, understood and agree to the above policies:
Patient Name*
Patient/Guardian Signature*

Clear
Guardian Name*
Date*

MonthDayYear
Date
Thank you for your cooperation and business.

Patient Consent for Telehealth Services
First Name*
MI*
Last Name*
DOB*

MonthDayYear
Date
Age*
Today's Date*

MonthDayYear
Date
CONSENT FOR TELEHEALTH SERVICES (Initial Below)
I understand that I will be engaging in Telehealth with Physical Therapy San Pedro for my therapy evaluation and/or treatment sessions.*
Initial Here
It has been explained to me how the video conference technology will be used to conduct my therapy session and that there will not be direct patient/physical therapist contact due to the I will not be in the same room as my physical therapist.*
Initial Here
I understand that there are potential limitations using this technology, including interruption, unauthorized access and technical difficulties. I understand that my physical therapist and/or I can discontinue the Telehealth session if it is felt that the videoconferencing connection is not adequate for the situation.*
Initial Here
I understand that my healthcare information may be shared with other Physical Therapy San Pedro staff for scheduling and billing purposes. The above-mentioned staff will maintain HIPAA confidentiality.*
Initial Here
The alternatives to a Telehealth session have been explained to me, and in choosing toparticipate in Telehealth session, I understand that some parts of the exam/therapy visit involvingphysical test/activities/ exercises may require the assistance of a caregiver/family member/ friend atmy location at the direction of my physical therapist to conduct and /or gaurd me as the patient toensure my safety.*
Initial Here
I understand that Physical Therapy San Pedro and my physical therapist responsibility of me,the patient, for a given session will conclude upon the termination of the video conference connection.*
Initial Here
I understand that Physical Therapy San Pedro will bill my session as usual to my insuranceprovider(s) as a physical therapy visit with the addition of using modifier codes to indicate my sessionwas performed virtually using video conferencing technology.*
Initial Here
I have had a direct conversation with Physical Therapy San Pedro staff and /or my physicaltherapist, during which I had the opportunity to ask questions in regard to my physical therapy. Myquestions have been answered and the risks, benefits, and any practical alternatives have beendiscussed with me in a language in which I understand.*
Initial Here

I, THE PATIENT OR RESPONSIBLE PARTY OF THE PATIENT, HAVE READ, UNDERSTAND, AND AGREE TO THE STATEMENTS CONTAINED HEREIN: (Initial Below)
I acknowledge I have been given ample opportunity to ask questions and that any questions been answered to my satisfaction.*
Initial Here
I acknowledge I fully understand its contents including the risk and benefits of Telehealth therapy sessions*
Initial Here
Patient's Name*
Patient/Guardian Signature*

Clear
Legal Guardian Name/Association*
Date*

MonthDayYear
Date
Should be Empty:

New Patient Intake Information

New Patient Paperwork (Insurance)

Informed Consent

Reassignment of Benefits

Cancellation/No-Show Policy

Patient Consent for Telehealth Services