CONSENT FOR TREATMENT

PREMIER PHYSICAL THERAPY & ASSOCIATES

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Oxnard North

Oxnard Seabridge

Moorpark

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Returning Patient

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CONSENT FOR TREATMENT

I hereby authorize the providers at Premier Physical Therapy & Associates to perform the treatments or procedures approved by my referring physician.

I acknowledge that no guarantees, either expressed or implied, have been made to me regarding the outcome of any treatments and/or procedures. I fully understand that it is impossible to make any guarantees regarding the outcome of any medical treatment or procedure.

I understand that it is fully my responsibility to be aware of what my private insurance covers and what i may/or may not be responsible for at the end of my treatment or procedure. I understand that I am financially responsible for any amount that is NOT covered by my contract.

I, the undersigned, authorize payment of medical benefits to Premier Physical Therapy & Associates for any services furnished to me by the provider. I also authorize you to release to my insurance company or their agents information concerning health care, advice, treatment, or supplies provided to me. This information will be used for the purpose of evaluation and administering claims of benefits.

Signature: CONSENT FOR TREATMENT

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NO-SHOW / CANCELLATION POLICY

We understand emergencies and other scheduling conflicts occur and can be unavoidable, however, advanced notification allows us to fulfill other patient's scheduling needs. Due to our 60-minute treatments, missed appointments are an inconvenience to your physical therapy, the clinic, and other patients.

1. Please provide our office with 24-hour notice to change or cancel an appointment. 24-hour notice allows us to place another patient in your cancelled appointment period to receive needed treatment.

2. Patients who do not attend a scheduled appointment and do not provide 24-hour notice to change a scheduled appointment will be responsible for a $25 office visit charge. This charge will not be covered by insurance.

3. Your treatment plan has been established by your physical therapist to get you back to your regular activities as quickly as possible. Missing appointments may delay that process and may prolong recovery.

4. After missing 3 appointments without notice, you will not be allowed to schedule any appointments in advance.

Thank you for providing our office and patients with this courtesy.

Signing below indicates you understand and agree to the terms of the policy.

If you refuse to sign, you will not be able to schedule in advance. You may only schedule on the same day you call.

Signature: NO-SHOW / CANCELLATION POLICY

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