Please include vitamins and over-the-counter medications
Treatment of Self or Minor
I hereby authorize and consent to treatments/services for myself, or on the behalf of the above-named patient, performed by the staff at Ascent Physical Therapy and Performance and/or as directed by my referring services.
Photo/Video Release
I grant to Ascent Physical Therapy and Performance and its affiliated entities, and its representatives and employees (collectively the “Company”) the right to take photographs and\or videos of me in connection with my participation in physical therapy services. I authorize the Company, to copyright, use and publish the same in print and/or electronically. I agree that the Company may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content and waive any right to compensation, therefore I understand that I may revoke this authorization but only in writing delivered to the clinic office manager. I understand that if I choose to revoke this Authorization, the revocation will not be effective for any uses and/or disclosures of my protected health information that have already been made in reliance on this Authorization. By clicking Yes and typing your name you are electronically signing this form.
Notice of Privacy
I acknowledge that I have received the practice/clinic’s Notice of Privacy (Located at the top of this page), which describes the ways in which the practice/clinic may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact Ascent if I have a question or complaint. I understand that this information may be disclosed electronically by the Provider and/or the Provider’s business associates. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice/ clinic’s Notice of Privacy. By clicking Agree and typing your name you are electronically signing this form. Financial Policy
Ascent Physical Therapy and Performance LLC contracts with several healthcare insurance programs. If your insurance plan is one of our contracted plans, we will bill your insurance on your behalf. Your payment method that is kept on file with be charged for any remaining balance not covered by insurance. This will occur if you have a deductible or co-insurance. It is your responsibility to pay any deductible amount, co-insurance, or any remaining balance left unpaid by your insurance provider. If we are filing claims with your insurance company, we are contractually obligated to collect your copay. We will collect it at the time of service. Our office does not bill copays. Co-pays are the patient’s responsibility and are due at the time of service. Physical Therapy is classified differently based on your insurance provider. Please check with your insurance company whether or not physical therapy is considered a specialty service. If your insurance carrier has a specific copay amount for specialty care, you will be expected to pay this amount at the time of service. We cannot waive co-pays, deductibles, or coinsurance for non-covered services defined as patient responsibility under the terms of our contract with various health plans.
Payment arrangements are required at the time of your visit. A payment method may be kept on file. I authorize Ascent Physical Therapy and Performance LLC to charge my payment method an amount equal to the balance of charges within 90 days of the date of service, but not to exceed $100 per date of service, and to store that card account information for future transactions. I understand that after insurance has processed a statement of any remaining balances over the authorized amount may be billed to me. I represent and warrant that I am the primary cardholder or authorized user of the card. This authorization is effective as of the date below and is reflected in Merchant’s record and will remain in full force and effect until I notify Merchant that I wish to revoke this authorization. I understand that payments made prior to my cancellation of this authorization are subject to Merchant’s general terms and conditions for refunds. I understand that Ascent Physical Therapy and Performance LLC will notify me by email, at the email address I have provided, of any changes to this authorization. I understand that it is my responsibility to update my information on file with the Merchant should my email address, contact, or card information change.
If you are a self-pay patient, you must pay in full at the time of service. Self-pay patients, who are new to the practice, will be required to pay $150 at the initial appointment. Your initial appointment includes evaluation and treatment. Established patient visits are $100 per visit. Discount may apply for pre-paying of visits.
Insurance Benefits
I authorize my insurance company to pay benefits directly to Ascent Physical Therapy and Performance and/or its clinicians. I understand that I am financially responsible for services rendered by the clinician and his/her staff as determined by my insurance company. I also understand that all copays are due at the time of my visit. I agree that all the above information is true and correct to the best of my knowledge. In accordance with HIPAA regulations, I acknowledge that I have been given a copy of Ascent Physical Therapy and Performance’s Notice of Health Information Practices.
The "Send Form" button will appear by selecting Yes to the authorizations above.
