CONSENT TO TREATMENT: I consent to rehabilitation and related services at Muscle Up Physical Therapy. In doing so, I understand, acknowledge and affirm that such rehab and related services may involve bodily contact, touching, and/ or direct contact of a sensitive nature (in office only)
TREATMENT OF MINORS: I, as a parent/ guardian of a minor receiving treatment hereunder, do hereby agree and understand that I have been advised to remain on the premise during any such treatment, and waive any claime I may have resulting from failure to do so.
LIABILITY: I know and agree that Muscle Up Physical Therapy is not responsible for loss or damage to person valuables.
WAIVER AND RELEASE: I hereby release, discharge, and acquit Muscle Up Physical Therapy, its agents, representatives, affiliates, employees, or assigns, of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive, or allow emergency and/ or medical services, including but not limited to ambulance service, Emergency Medical Technician, physician, or urgent care services.
AUTHORIZATION OF PAYMENT: I understand fully I am responsible for paying for services rendered by Muscle Up Physical Therapy at the time of service. I also understand that if I cancel my appointment within 24 hours of my scheduled session, I am still responsible to pay Muscle Up Physical Therapy the full amount for the scheduled appointment upon returning for my next appointment. I hereby assign all benefits directly to Muscle Up Physical Therapy and also authorize release of any medical records necessary to facilitate my treatment to process medical claims and as otherwise permitted or required in the Notice of Privacy Practices.
BENEFIT VERIFICATION: I understand that Muscle Up Physical Therapy does not bill my insurance carrier directly, but will provide me with the necessary paperwork to submit a self-claim outside of my appointment time. By submitting a self-claim, I understand that my insurance carrier may or may not cover the services rendered and that I am ultimately financially responsible. Muscle Up Physical Therapy will provide medical records and receipts for services rendered at request.
NOTICE OF PRIVACY: I acknowledge receipt of Notice of Privacy Practices (click link below).
I understand that by writing my first and last name below, it replaces my signature with an electronic signature for this form.