CONSENT:

1. I consent to participate in physical therapy services at STAR Spine Therapy & Amputee Rehabilitation, PLLC, Therapy SPOT - Bellaire, and/or Associates of Physical Therapy Specialists, PLLC. I acknowledge that participation in physical exercise and rehabilitation may involve the use of exercise equipment and devices and poses potential risks of bodily injury or death.

2. I hereby accept the responsibility for any harm, injury, or damage that may result from my participation in physical exercise and/or training. I hereby waive, release, absolve, indemnify, and agree to hold harmless STAR Spine Therapy & Amputee Rehabilitation, PLLC, Therapy SPOT - Bellaire, and/or Associates of Physical Therapy Specialists, PLLC, its officers, employees, and affiliates for any claim arising out of any injury to me as a result of negligence or any cause. I voluntarily and knowingly acknowledge, accept, and assume these risks.

3. I understand that the practice of physical therapy, although strong efforts are made to utilize best practice, is not an exact science and that no guarantees or promises have been made to me as a result of treatments or examinations by the physical therapist or supportive personnel. I understand that no contract, warranty, guarantee, or promise concerning the results of physical therapy services is made.


RELEASE OF INFORMATION:

1. STAR Spine Therapy & Amputee Rehabilitation, PLLC, Therapy SPOT - Bellaire, and/or Associates of Physical Therapy Specialists, PLLC releases patient health care information for purposes of treatment or payment, or to other health care organizations as outlined in our “Notice of Privacy Practices.” I authorize the release of any medical, financial, or other information pertinent to my case to any insurance company, adjuster, attorney, or third-party payer involved in this case for the purpose of processing claims and securing payment of benefits.

2. I have read the “Notice of Privacy Practices” and understand that a copy of the notice will be provided to me upon my request.


INSURANCE and PAYMENT:

1. I authorize the staff at STAR Spine Therapy & Amputee Rehabilitation, PLLC, Therapy SPOT - Bellaire, and/or Associates of Physical Therapy Specialists, PLLC to obtain and review my health insurance coverage in the manner that it is available from my insurance company.

2. I understand that my insurance benefits are only a quote of benefits and are not a guarantee of payment. I understand that it is my responsibility as a patient to know my insurance coverage and that insurance coverage is an arrangement between the carrier and the patient.

3. I acknowledge that I will be ultimately responsible for payment of services rendered at this facility. I agree to pay in full any and all charges not covered by insurance or other benefits. I understand that it is unlawful to waive copays, co- insurance, and deductibles that are my responsibility.

4. I authorize payment to be made from my insurance company directly to STAR Spine Therapy & Amputee Rehabilitation, PLLC, Therapy SPOT - Bellaire, and/or Associates of Physical Therapy Specialists, PLLC for services rendered.

5. I agree to pay my bill at the time of service unless other arrangements have been made with the Billing Department.

6. There will be a fee of $45.00 for any returned checks.

7. I understand that if my financial arrangement is not fulfilled as agreed, my account will be transferred to an outside agency to assist in collecting the remaining balance. A 35% fee will be added to the unpaid balance and will be my financial responsibility.

8. Medicare patients: Please see attached “Notice to Medicare Patients.”


LATE/CANCELLATION/NO SHOW POLICY:

1. Please make every effort to be on time for your appointment. If you show up late, your therapist may not have the time to treat you, or your therapy time may be reduced. Please call the office if you know that you will be late. You may be asked to reschedule your appointment.

2. If you must change or cancel your appointment, please call 24 hours in advance. Same day cancellations and no-show appointments are liable to a $45.00 charge to your account.

3. I understand that it is my responsibility to keep track of my scheduled appointments. I understand that it is a courtesy of the office to send me a patient appointment reminder. I will contact the office with any questions regarding my schedule.

4. If you have 3 consecutive last minute cancellations or no-show appointments, we will have to remove your recurring appointments from our calendar. Consistent no-shows will result in the termination of the therapist/patient relationship.