Minor Patient Treatment Consent Form
  • Minor Patient Treatment Consent Form

    8975 Guilford Rd Ste 170, Columbia, MD 21046
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  • IMPORTANT RULES & POLICIES

  • 1. Late Policy: If I’m late more than 10-minutes to my appointment, I may be rescheduled or asked to wait for next available open time slot.
    2. Co-pays, coinsurances, and/or deductibles are due prior to treatment starts.
    3. Not showing for an appointment without notice may result in a $60 fee added to my account.
    4. Cell phones must be shut OFF or silent. There is no recording audio/visual allowed in the practice.
    5. Children requiring supervision are NOT allowed to attend sessions with you without prior authorization.
    6. If you are experiencing any financial hardship, please notify us immediately so we can create a feasible payment program.
    7. I declare under penalty of perjury in the State of Maryland that the insurance information is true and correct, this is not a third party (someone else) insurance, and that I am a direct beneficiary (self, spouse, child) of the policy holder.
    8. We are here to help you make informed decisions regarding your payment options to cover the COC (Cost of Care), however, you are responsible for verifying your benefits with your health insurance if you wish to use that to cover your payments for services rendered. We offer a complimentary benefits verification with you, ask our Front Desk about it. You are also responsible for changes of your insurance, work compensation information, or auto / vehicular accident case with / without lawyer.
    9. You may receive through text / email about blogs / podcasts / events and any other communication from AAA PT.
    10. If for any reason you are NOT satisfied with the care received, please contact our administrator at 443-979-7171 or admin@aaaphysicaltherapy.com.
    11. I was informed that billing information such as cost of care verification, statements and account balances are sent through a safe online portal and an email will be sent to notify for the link to access and make payments.

  • Guidelines & Procedures

  • 1. A HEALTH SCREEN is required prior to setting an appointment ONSITE. Health screens are conducted for staff and patients.

    2. In the event that you are feeling under the weather and exhibiting sign and symptoms, we ask that you consider an ONLINE appointment with your physical therapist in lieu of an onsite visit.

    3. Wearing of Masks is required for all staff. However, patients are encouraged to wear mask as a precaution, but not mandatory.

    4. We have NO FRONTDESK AREA WAITING POLICY in place at this time.

    5. Online check in (no manual sign in) is enforced to minimize contact.

    6. Staying 6 feet social distancing inside the clinic unless treated hands on by your Physical Therapist with your permission.

    7. Hand washing is REQUIRED before and after treatment by both patient and staff.

    8. Sanitation and disinfection of equipment, tables, mats and contact surfaces every after use with hospital grade approved agents.

    9. Our PTs continue to provide Telehealth care even if they are ONSITE.

    10. Our PTAs and Techs continue to help us ONSITE and ONLINE.

    11. NO WALK INS allowed at this time. SAME DAY APPOINTMENTS available. CALL AHEAD!

  • CONFORME:

    I hereby give my permission as parent/guardian for the minor child, to receive treatment from AAA Physical Therapy, LLC.” 

    In consideration of my minor child’s participation in Physical Therapy services with AAA Physical Therapy, LLC, I hereby release AAA Physical Therapy (its employees and owners), from any claims, demands, and causes of action arising from my minor child’s participation in the Physical Therapy program. 

    I hereby release AAA Physical Therapy, LLC from liability now or in the future during the treatment of my minor child.

    I understand that, in my absence, my minor child will make decisions regarding Physical Therapy services and I will be responsible for all charges associated with those services.

    I hereby affirm that I have read and fully understand the above.

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  •  p. 443.979.7171 AAA Physical Therapy, LLC
    admin@AAAPhysicalTherapy.com
    8975 Guilford Rd Ste 170 Columbia, MD 21046
     f. 667.200.5908
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