Registration Packet

I hereby authorize and consent to treatment/services for myself, or on behalf of the above-named patient performed by the staff at Health In Motion and/or as directed by my referring provider. I understand that I have the right to ask and have any questions answered prior to receiving any treatment, including risk or alternatives to the recommended treatment plan.

I assign payment for these services directly to Health In Motion. I authorize the filing of claims to my insurance plan and authorize Health In Motion to release necessary health information related to these services to process the claims. I certify that the information I have provided is accurate and complete.

In signing this form, I will promptly pay any required co-pay, coinsurance and/or deductible amounts. I accept that insurance plans may deny payments for what I believed were covered services, resulting in my responsibility for paying for these services.

I acknowledge that I have received the Notice of Privacy Practices, which describes the ways the practice may use or disclose my healthcare information. I understand that my healthcare information may be used for treatment, payment, healthcare operations and other permitted uses or disclosures as described in the Notice.

By providing my above contact information and signing below, I consent and authorize Health In Motion and its related entities, agents, contractors, including but not limited to scheduling, billing, and other departments to use automated telephone dialing systems, SMS text messaging, and electronic mail to (1) provide messages (including prerecorded messages or text messages) to me about appointment reminders, patient surveys, my account, payment due dates, missed payments, information for or related to medical goods and/or therapy services provided, exchange information, changes to health care law, health care coverage, care follow-up, and other healthcare information or (2) provide messages (including pre-recorded messages) during a call or via text message that delivers a ‘health care’ message made by, or on behalf of, a ‘covered entity’ or its ‘business associate’ as those terms are defined in the HIPAA Privacy Rule, 45 CFR 160.103. I understand that providing a telephone number and/or email address is not a condition of receiving medical services. 

I also understand that I may revoke my consent to contact at any time by directly contacting Health In Motion or using the opt-out method that will be identified in the applicable communication. I also understand that it is my responsibility to notify Health In Motion immediately of any change in telephone number or email address.

Payment for services is due at the time services are rendered

We will verify your benefits with your insurance carrier. However, this does not guarantee that they will cover the prescribed treatment. By signing below, you are acknowledging that you are responsible for deductibles, copays, coinsurance, and non-covered services not paid by the insurance carrier and understand that you are fully responsible for any balance due for services rendered.

Regular attendance at therapy sessions is crucial for you to recover fully and return to the activities you love! When an appointment is missed, it’s a missed opportunity for progress in your recovery, and it impacts our ability to accommodate other patients who may need urgent care. If you need to cancel or reschedule, please call the clinic. It is the policy of Health In Motion to monitor and manage appointment no-shows and late cancellations. 

Scheduled appointments must be cancelled or rescheduled at least 24 hours prior.

Failure to attend your appointment without 24-hour notice may result in a fee of $50 that will be charged directly to you as the patient (not insurance) for each instance of a missed appointment. This fee is due to be paid at or before your next visit.