Patient Information Consent Form


Patient Information Consent Form

Consent to Physical Therapy Evaluation and Treatment

I hereby consent to the evaluation and treatment of my condition by a licensed physical therapist employed by Athletic Evolution Physical Therapy. The Physical Therapist will explain the nature and purposes of these procedures, evaluation, and course of treatment. The physical therapist will inform me of expected benefits and complications, and any discomforts, and the risk that may arise, as well as alternatives to the proposed treatment and the risk and consequences of no treatment.

Assignment of Benefits and Insurance Proceeds

I authorize payment of medical benefits to Athletic Evolution Physical Therapy for services rendered. Athletic Evolution Physical Therapy will make a reasonable effort to collect insurance proceeds by completing insurance forms and sending the forms to the insurance company. Completion of such forms and/or the acceptance of assignment of insurance benefits does not relieve the undersigned of the obligation to the amount owed for physical therapy.

Patient Information Consent Form (HIPAA)

I have read and fully understand Athletic Evolution Physical Therapy’s Notice of Information Practices. I understand that Athletic Evolution Physical Therapy may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment, evaluating the quality of service provided, and any administrative operations related to treatment or payment. I understand that I have the right to request restrictions, in writing, regarding how my personal health information is used and disclosed for treatment, payment, and administrative operations. I also understand that Athletic Evolution Physical Therapy will consider all requests for restrictions on a case by case basis, but is not required to oblige to such requests.

Release of Information

I hereby authorize the release of information necessary to file claims with my insurance company. I permit a copy of this authorization to be used in place of the original.

Late Cancel/No Show Policy

I hereby accept the late fee/no show policy. If I do not call at least 6 hours prior to my appointment time, there will be a $30 cancellation fee. Failure to call or show for an appointment will result in a $50 NO Show fee.

I have read and understand the above consents, assignment of benefits, release of information, and late cancel/no show policy above and I am 18 years of age or older.

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This is to certify that I, as parent/guardian with legal responsibility for this patient, have read and understand the above consents, assignment of benefits, release of information, and late cancel/no show policy above, and I agree to his/her consent. I further understand that I assume liability for all aforementioned policies and procedures of the minor patient, as well as all penalties and fees outlined above.

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