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.

If you do not want HIM to file claims to your personal health insurance, please read and sign below or please indicate if you do not have personal health insurance and sign below. I acknowledge that I understand and agree that:

• I am covered by the health insurance plan.
• The Health Plan under which I am covered includes benefits for some or all the services provided by HIM.
• Despite the above, I do not wish HIM to submit a claim to my Health Plan for services provided to me.
• Until such time as I may otherwise advise HIM in writing, I elect to pay for all services I receive at their self-pay rates.
• By election to self-pay for services, I understand that HIM will not be submitting claims to my Health Plan and that any payments I make to HIM will NOT be credited toward satisfying any deductibles, plan maximums, etc.
• I have read the Election to Self-Pay for Services and have had the opportunity to ask any questions I may have, and my questions have been answered to my satisfaction.

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.