Endurance PT Intake Forms

Patient Consent Section

Please ensure you have read the entirety of the form hosted on our website. Please contact us at (626) 639-2808 by phone or by text if you have any questions about the content of this form or were unable to load it online. We will be happy to provide an emailed or in-person paper copy to you. Thank you!
Name

First NameLast Name
Initial here to consent to treatment (see below)
I consent to physical therapy and wellness services at Endurance Physical Therapy. Bysigning this form, I am acknowledging that I understand the risks and benefits of theseservices. I understand that I may, at times, see an increase in my symptoms. I know if Ihave any questions about my care, I should be sure to ask the therapist or staff about them.I know it is up to me to inform the therapist or staff about any health problems or allergies Ihave. I understand that I must also tell the therapist or staff about drugs or medications I am taking.
Initial here regarding insurance (see below)
I authorize the staff at Endurance to review my insurance coverage with my insurance company. I understand that my insurance benefits are only a quote of benefits and not a guarantee of payment. I understand that what I am quoted by Endurance and/or my insurance company may differ from what I may owe at the conclusion of services. I understand it is my responsibility as the patient to know my insurance coverage. I authorize payment of my insurance benefits to be made directly to Endurance Physical Therapy. I agree to pay in full any and all charges not paid by insurance or otherbenefits. I understand that Endurance cannot waive co-pays, co-insurances, and deductibles that are my responsibility.
Initial here regarding release of health information (see below)
Endurance releases patient health care information for purposes of treatment, payment, or to other health care organizations. I authorize the release of any medical or other information pertinent to my case to any insurance company, adjuster, or attorney involved in this case for the purpose of processing claims and securing payment of benefits. I understand that I may restrict my personal health information from anyone by submitting a written request. Please see our notice of privacy practices
Initial here regarding privacy practice (see below)
I have read the Endurance Statement of Privacy Notice and I understand that a copy of the notice will be provided to me upon my request.
Patient/guardian signature regarding receipt of a copy of the Notice of Privacy Practices
Initial here regarding communications about your account (see below)
I agree that Endurance or any other collection or servicing agency or agencies retained by Endurance (collectively called agencies) to collect any money that I owe to Endurance may contact me by telephone or text message at any number given by me or that is or becomes associated with me or my account from sources other than me, including but not limited to, cellular/wireless telephone numbers which may result in my incurring fees for the call or textmessage. I understand, acknowledge and agree that the agencies may contact me by automatic dialing devices and through pre-recorded messages, artificial voice messages or voice mail messages. I further agree that the agencies may contact me using e-mail at any e-mail address I provide to the Endurance or is otherwise associated with my account.
Initial here regarding email communication (see below)
I consent for Endurance to use email correspondence during my time of service. Providers cannot guarantee but will use reasonable means to maintain security and confidentiality of e-mail information sent and received. Providers are not liable for improper disclosure of confidential information that is not caused by Provider’s intentional misconduct.
I consent and agree for Endurance to have the right to take photographs, digital video, or other digital recordings of me and to use these for (select one or none):
I certify that any and all information provided by me is true. I have read the information on the front and back of this form or on the entirety of this web form. It has been fully explained to me and all of my questions have been answered. (Patient/guardian signature)
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MonthDayYear
Date

Cancellation and No-Show Policy
Initial here regarding cancellation/no-show policy (see below)
As of January 5, 2026, our new cancellation policy is as follows:
- Notice given 2 business days before your appointment (i.e. on Wednesday, for a Friday appointment): No charge
- Notice given the business day before your appointment (i.e. on Thursday, for a Friday appointment): $75 charge
- Same-day cancellations or no-shows: $100 charge
We will collect your credit card information when you schedule your first session with us, and save it on our secure payment processor. If you do not have a credit card saved on file with us, we will collect the above fee at your next appointment, or by phone at your earliest convenience. If there are mitigating circumstances to your cancellation you are welcome to discuss this with your treating physical therapist or with our patient coordinator(s).
Patient/guardian signature regarding understanding of cancellation policy

FOR PATIENTS ENROLLED IN MEDICARE PART B ONLY

IF YOU DO NOT HAVE MEDICARE, PLEASE SCROLL DOWN AND CLICK "CONTINUE"
As of June 15, 2026, to enable us to meet our obligations to our staff in light of changing insurance landscapes, Endurance Physical Therapy is phasing out its relationship with Medicare Part B for new patients.

As has been explained to me, we are no longer accepting Medicare PT benefits for new patients. However, we are now offering a reduced rate for individuals over 65 years of age who are enrolled in Medicare Part B (or for individuals who are under 65 years of age and are enrolled in Medicare Part B for a non age-related reason). As of June 15th, 2026, that rate is $125 per visit.

This section of our online intakes fills out a PDF copy of the Medicare "Advance Beneficiary Notice of Non-Coverage (ABN)" form, which is a standard Medicare form available online. An image of the form is on the next page.

Once you have begun treatment here, you may revoke your decision to seek care here at any time without penalty (and you will not be subject to our cancellation policy in doing so), and we will happily provide you with referrals to appropriate clinics which are accepting new Medicare Part B patients, as well as continue treating you for up to 2 weeks if you wish.

If we return to accepting new Medicare Part B benefits at a later date, we will inform you, and we will begin accepting your benefits at and as of that date, nullifying this ABN at that time.

This page reflects only an Endurance Physical Therapy clinic policy, not a Medicare policy or decision.
Please type your name below to acknowledge and proceed.
Choose one option below. Please ask us any questions you have.
Please sign here to acknowledge your choice.
Today's Date

MonthDayYear
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As of June 15, 2026, to enable us to meet our obligations to our staff, Endurance Physical Therapy is phasing out its relationship with Medicare Part B. As a result, we are no longer accepting Medicare PT benefits for new patients. However, we are extending a reduced rate of $125 for individuals over 65 years of age (or for individuals who are under 65 years of age and are enrolled in Medicare Part B for a non age-related reason). Please type your name below to acknowledge and proceed.
- The Federal Government has placed a “cap” (limitation) on your physical therapy benefits. The maximum that Medicare will pay for physical therapy and speech therapy is $2,300 for the calendar year 2024. This effectively translates into approximately 19-22 visits. Please let us know if you have previously received physical therapy or speech therapy elsewhere this year.
- You do not automatically qualify to use all of your therapy up to the cap—the therapy must meet the standards for medically necessary care. In order to qualify formedically necessary care, you must demonstrate:
  - 1) Self-management: You will be an active participant in your plan. You must commit to and participate regularly in a program outside of therapy to change your health.
  - 2) Progress toward goals: Medicare looks for you making regular progress toward the functional goals that you set with your therapist. Your therapist will set objective and measurable goals with you at your first session and then regularly check in on the goals. Significant progress towards those goals within a reasonable time frame is necessary. The goals must specifically be related to function, not performance enhancing.
  - 3) Commitment to the plan. Your therapist will develop a plan with you for a number of visits in a certain amount of time in order to reach your goals. It is imperative to commit to the prescribed schedule in order to make the changes you desire.
- In many circumstances, treatment beyond the “cap” is medically justified. If you wish for your treatments to exceed the “cap”, you are responsible for any amount that is not covered by either Medicare or a secondary insurance. Visits beyond the “cap” will be charged to you at our usual and customary visit charge.
- Your Costs: Unless you have secondary or supplemental insurance that covers your cost, you are responsible for an annual deductible of $233.00 and the 20% co-insurance amount.
- Medicare Part B provides outpatient physical therapy benefits at Endurance
  - ONLY IF you are not also receiving home health services
  - ONLY IF you are not receiving physical therapy at another clinic
  - ONLY IF your therapy is determined to be medically necessary
  - ONLY IF you are not part of a Medicare HMO (Endurance is not part of a Medicare HMO)
Are you currently receiving Home Health Care (including nursing) via Medicare?
Initial regarding medically necessary PT (see below)
What is Medically Necessary Physical Therapy?
- According to the Medicare guideline: “The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a therapist. Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they areperformed or supervised by a qualified professional.”
- There is an expectation of significant improvement within a reasonable time frame.
- The medical necessity relates to the achievement of specific functional goals that Medicare deems appropriate, and not related to performance or recreational activities.
- Medically necessary physical therapy should be utilized to prepare you for functional independence, wellness programs, community programs, ongoing home program, etc.
- It does not matter whether your doctor has written a new prescription for therapy oradds a different diagnosis. Medical necessity is made by a decision of your therapist whether a high level of skill and complexity is needed for your treatment.
Initial regarding uncovered therapy (see below)
What therapy services may not be covered by Medicare?
- Prevention, wellness, fitness services or group exercise classes.
- If your plan was not supported by your physician (we must get your physician’s signatureevery 90 days).
- Services that are not “reasonable and medically necessary”, which include any servicethat can be self-administered or provided by a caregiver, personal trainer or other provider.
- Examples of services that are not reasonable or medically necessary include:
  - Doing an exercise program because it is hard for you to exercise on your own
  - Ongoing massage and stretching
  - Fitness exercise
  - Athletic performance or recreational activities
  - Traveling-related goals
I have read and understand the above statements regarding my Medicare physical therapy benefits. I am responsible for all treatment charges, beyond the Medicare “cap,” whether or not they are covered by insurance, unless prior arrangements have been made with Endurance Physical Therapy.
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SAMPLE ABN FORM -- FOR REFERENCE ONLY
Should be Empty:

Endurance PT Online Intake Form

Patient Consent Section

Cancellation and No-Show Policy

FOR PATIENTS ENROLLED IN MEDICARE PART B ONLY

SAMPLE ABN FORM -- FOR REFERENCE ONLY