Permission for Treatment:

I acknowledge that physical therapy involves the use of many different types of physical evaluation and treatment. As with all forms of medical treatment there are inherent benefits and risks involved with physical therapy. As a physical response to specific treatments can vary widely from person to person, it is not always possible to accurately predict the patient’s response to certain modalities or procedures, not can it be guaranteed that the treatment will inherently help the condition the patient is seeking treatment for. There is also always a risk that the treatment(s) may cause pain, injury or exacerbate pre-existing conditions. I have the right to ask the physical therapist what type of treatment he/she is planning based on my medical history, diagnosis, symptoms and testing results. I may ask the therapist about the potential risks and benefits of a specific treatment before, during or after the intervention.I understand I have the right to decline any portion of the treatment at any time before or during the treatment session.

Health Insurance:

I understand that Trinity Physical Therapy does not bill insurance companies and serves as an out of network provider. Trinity Physical Therapy will provide you with receipts for all treatment received for you to submit to insurance companies if requested. Trinity Physical Therapy does not make any guarantees that your insurance provider will cover any services provided. Trinity Physical Therapy requires that your show government issued photo identification if you are requesting receipts with patient information on them.

Charges/Guarantee of Payment:

I understand that Trinity Physical Therapy charges a fee for appointments and I agree to pay Trinity Physical Therapy all charges at the time of service. If paying with check, and the check is returned due to insufficient funds, I agree to pay Trinity Physical Therapy $40 for fees associated with the returned check and any additional costs that Trinity Physical Therapy incurs to collect the balance owed, including, but not limited to, attorney fees, court costs, and collection agency costs.

Cancellation Policy:

I understand that in the event that I am unable to keep an appointment, I will contact my therapist as quickly as possible. Visits that are cancelled less than 24 hours prior to the scheduled visit time, or are not cancelled at all will be billed one half the session charge for the first visit. Each subsequent short notice cancellation will be charged for a full visit. Email, phone call or messaging through the PTEverywhere patient portal are suitable means to communicate visit cancellations. In the event of an emergency, the cancellation fee will be waived only at the discretion of the owner. Multiple infraction of the Cancellation Policy can warrant involuntary discharge of the patient from treatment at Trinity Physical Therapy. This is at the discretion of the primary treating therapist. 

Patient Conduct:

I agree that Trinity Physical Therapy can stop providing care at any time for any reason. I agree and acknowledge that I may have additional people present at the time of the appointment. By requesting additional people be present at your appointment, I agree and acknowledge that I am authorizing the release of medical information to such individuals in the form of any discussions that take place during such appointment.

Communication:

I understand that I may be contacted by Trinity Physical Therapy staff via email, phone call &/or text messaging to be reminded of an appointment, to obtain feedback on their experience with this facility, &/or provide general health reminders and information. I give permission to for Trinity PT staff to leave messages on any voicemail given.

Video/Social Media Authorization:

I hereby authorize Trinity PT to use any written messages, pictures or videos as testimonials on social media and other marketing platforms.  Verbal authorization will be obtained prior to each posting.

Minors:

I understand that Trinity Physical Therapy requires that a parent or legal guardian be present during the initial evaluation for minors.

HIPAA:

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

1. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
2. Obtain payment.
3. Conduct normal healthcare operations such as quality assessments and physician certifications as indicated.

I understand that Trinity Physical Therapy will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. 

I have ready and fully understand that I may request in writing that Trinity Physical Therapy restricts how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand that Trinity Physical Therapy is not required to agree to my requested restrictions, but if the owner does agree, then she is bound to abide by such restrictions. 

I understand that I may revoke this consent in writing at any time, except to the extent that Trinity Physical Therapy has taken action relying on this consent.