* I consent to evaluation and treatment by HTC Physical Therapy and Wellness Clinic and Performance Center and realize that I have right to refuse any procedure after having the risks and benefits explained to me
* I have received a copy of Notice of Information/ Privacy Practices.
Type a label* I understand that HTC Physical Therapy and Wellness is not responsible for any lost or stolen of my personal property at or in the vicinity of the clinic location. I am fully responsible for that.
* The filling of Insurace claims is a courtesy that we extend to our patients. You will be responsible for any charges not reimbursed or contractually adjusted by your insurance company. Should your claims not process as you expected or should have any questions regarding your insurance plan benefits, please contact your insurance company directly.
* I authorize release of information acquired in the course of my treatment including by not limited to medical records, electronic media, and oral communications, to my insurance company represtatives, employer, primary care physician, referring physician, other third party payers and/ or the following Type a label*
* Should a patient account become 90 days past due the account will placed with a collection agency and a $40.00 collection fee will be charged.
* I authorize phone, e-mail, and/or text messages regarding my treatment and appointments to be left with persons or machines at the phone numbers provided
* I understand that in order to protect the confidentiality of our patients, there can be no filming, going "live" via social media or taking picture of my treatment, or that of other patients, without prior authorization from the Clinic Director.
* I hereby assign to HTC Physcial Therapy and Wellness Clinic all payment for medical services rendered to myself or my dependents. I understand I am responsible for any amount not covered by my insurance.
* I understand I will be charges a fee of $30.00 for canceled or missed appointments without 24 hour notice. Payment must be rendered prior to next scheduled visit.