Muscle Up Physical Therapy presents

Calls with Kelsey!

*For West Virginia residents only*

Don't live close to my office? It's hard to get time off of work once a week to drive up, attend your appointment, and drive back down.

Let's get the consult done online and save you time during your work week, then sign up for hands-on treatments at an off-site location!

Off-site appointments will be made on Saturdays from 8am-12pm on dates and at places TBD with permission granted by the gym owner.

Set up an appointment, fill out the paper work below, and hop on Skype for a private consultation!

This can be used for:

An initial evaluation during the week before I travel to treat in a location near you;

A quick check up if it's been a while since you've been treated to make sure you're on the right track;

Concern of injury, but unable to leave the house due to transportation or injury/ illness.

Appointments will be 20-30 minutes in duration and will be $40 per consultation.

Find me on Skype at KelseyDPT31@gmail.com

 


PLEASE FILL OUT THE FORMS BELOW PRIOR TO YOUR FIRST APPOINTMENT. PLEASE CONTACT ME FOR QUESTIONS OR CONCERNS.

CONSENT FORM
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.
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VIDEO CHAT CONSENT
I, the below named patient, understand that I must have Skype downloaded onto my phone or computer with picture and sound access as well as space to move on screen for assessment in order to participate in my consultation. 
I understand that I must provide Muscle Up Physical Therapy my username or email login for my Skype account in order to perform the online consultation prior to the scheduled time, either via email, text message, or phone call. 
I understand that Muscle Up Physical Therapy will perform these consultations over a secured wireless network with no other patients or people present, however there is no guarantee of security of privacy. I release Muscle Up Physical Therapy to use Skype to interact with me for physical therapy consultation with these risks in mind. 
I understand that by writing my name below, it replaces my signature with an electronic signature for this form.
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CANCELLATION POLICY
By signing this agreement, I understand that if I cancel an appointment at the Muscle Up Physical Therapy office or an online consultation within 24 hours of its scheduled time or if I do not show up to my scheduled appointment, I will be responsible to pay the full amount of the the appointment scheduled at the start of my next appointment on top of the new appointment's regularly scheduled appointment charge.
I understand that in order to not pay the cancellation fee, I am required to contact Muscle Up Physcial Therapy more than 24 hours prior to my scheduled appointment for online or in office visits and more than 48 hours prior to my scheduled appointment for off-site appointments to reschedule, as others may have needed that time slot for their own care.
24 HOURS NOTICE FOR ONLINE AND IN-OFFICE VISITS, 48 HOURS NOTICE FOR OFF-SITE VISITS.
I understand that if I am scheduled for treatment with Muscle Up Physical Therapy at an off-site location, I must provide at least 48 hours of notice if I need to cancel or reschedule my appointment. If I cancel within 48 hours of my appointment, I am responsible for the price of the appointment, and I give Muscle Up Physcial Therapy permission to charge my credit card on my account.
I understand that by writing my name below, it replaces my signature with an electronic signature for this form.
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MEDBRIDGE RELEASE FORM
I, patient name stated below, give Muscle Up Physical Therapy permission to use my contact information for the purpose of sending my personalized home exercise program via MedBridge Education. I understand that through this information, I will receive an access code with my personal program in the patient portal through the Medbridge site or through the MedBridgeGO app. I understand that this will be my code and Muscle Up Physical Therapy will only have access to them in order to change them as necessary.
I understand that by writing my name below, it replaces my signature with an electronic signature for this form.
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OFF SITE CONSENT TO TREATMENT
I understand that by doing an off-site visit, Muscle Up Physical Therapy cannot provide receipts to be sent to private insurance companies for coverage as these services are not rendered in the Muscle Up Physical Therapy office. Therefore, I understand that I am responsible for payment at the time of the service either by cash, check, credit card, or HSA/FSA card.
I understand that by doing an off-site visit, there is no guarantee for privacy as Muscle Up Physical Therapy may or may not have access to a private room. I understand Muscle Up Physical Therapy will perform draping and coverage as much as possible during treatment to maintain patient modesty. I understand that if I do not feel comfortable with treatments in the off-site location, I do not have to schedule appointments during that time frame and can opt to making appointments at the Muscle Up Physical Therapy office during normal office hours instead.
I understand that by writing my name below, it replaces my signature with an electronic signature for this form.
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CREDIT CARD PAYMENT AUTHORIZATION FORM
Sign and complete this form to authorize Muscle Up Physical Therapy to make a debit to your credit card listed below.

By signing this form, you give Muscle Up Physical Therapy permission to debit your account for the amount of cost for scheduled appointment based on type (evaluation, online consultation, follow up visit) or for cancellation fee. This permission is for payments related to services only and does not provide authorization for any additional unrelated debits or credits to your account.

*This website is secured and information goes straight to Muscle Up Physical Therapy. Your card information will be saved under your personal account on Muscle Up Physical Therapy's Square account. However, if you do not feel comfortable completing this form, you may provide your credit card information upon your first visit to Muscle Up Physical Therapy, including your online consultation.

Name on card

Name on card

mm/yyyy

3 or 4 digit code on back of card


I understand that by writing my name below, it replaces my signature with an electronic signature for this form.
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Thank you for taking the time to complete these forms. If you have any questions or concerns, please don't hesitate to contact me.

Please be sure that you have spoken with me to schedule your appointment time, no walk-ins taken.

Call or Text : 304-278-4290 (text message preferred, unable to answer calls during patient care)

Email: KelseyDPT31@gmail.com

Telephone: (304) 278-4290
Email: kelseydpt31@gmail.com

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