Consent and Release

Please initial your authorization
Cancellations/Changes: I understand and agree that if I need to cancel/change an appointment, I will give at least 24 hour notice or, if ill, I will call by 8AM the day of my appointment. If we are unavailable, you may leave a message on our answering machine. Please do not text. We reserve the right to charge $36.00 if you miss or cancel your appointment without the 24 hour notice. Allied Physical Therapy reserves the right to discontinue treatment of a patient with a history of broken or missed appointments.

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Physical Therapy Benefits: I understand my physical therapy benefits, including any limitations, of my insurance plan. I understand that insurance co-pays, co-insurance, and deductibles are due at each visit. If I do not have insurance, I understand payment is due in full at the time of appointment. I understand and agree that I am ultimately responsible for the balance on my account for professional services rendered by Allied Physical Therapy. I understand that I am financially responsible in the event that all of some payment is denied or not covered by my insurance carrier(s) or other third parties thatare responsible for payment. I request that payment of authorized benefits be made on my behalf to Allied Physical Therapy. If this claim is paid to the patient instead of the provider, I agree to endorse the check to Allied Physical Therapy or send payment directly to Allied Physical Therapy within the same day of receiving payment.

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Notice of Privacy Practices: I understand that I can request a copy of the Notice of Privacy Practices at Allied Physical Therapy. The notice is posted at Allied Physical Therapy and I can inquire about the practice’s Notice of Privacy Practices at the front desk.

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Consent for Care and Treatment: I, the undersigned, so hereby agree and give my consent and authorization for Allied Physical Therapy to provide examination, treatments and services by a physical therapist to myself/designee. I realize and certify that no guarantee or assurance has been made as to the results that may be obtained for such examinations, treatments and services.

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Release of Records: I authorize Allied Physical Therapy to release any and all requested information pertaining to treatment necessary to process a claim(s) for physical therapy benefits (Physician, Insurance Company, Attorney, Etc.). I authorize Allied Physical Therapy to obtain medical records / reports as they pertain to my diagnosis, treatment, prognosis and other pertinent data to my treatment.

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I authorize Allied Physical Therapy to release records to my spouse, parents, and adult children.

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I authorize Allied Physical Therapy to release records to:
Relationship
Your Initials
Signature
Date of Birth
MM slash DD slash YYYY
Date
MM slash DD slash YYYY

Consent and Release

Please initial your authorization