1. I understand and agree that I will be financially responsible for any and all charges for services not paid by my insurance for my visits.
2. I understand and agree it is my responsibility, and not the responsibility of PT Professionals, to know if my insurance will pay for medical services provided by this office.
3. I understand and agree it is MY RESPONSIBILITY TO KNOW IF MY INSURANCE HAS A DEDUCTIBLE, OUT OF POCKET EXPENSES, CO-INSURANCE, CO-PAYMENTS, POSSIBLE OUT OF NETWORK EXPENSES, ANY OTHER TYPE OF BENEFIT LIMITATIONS, AND I AGREE TO MAKE FULL PAYMENT WHENEVER REQUIRED!
4. I understand and agree IT IS MY RESPONSIBILITY TO KNOW IF PT PROFESSIONALS IS IN-NETWORK with my insurance. If the office is considered out-of-network, it may result in claims being denied or a higher out of pocket expense to me. I understand this and agree to be financially responsible and make full payment. However, we are a participating provider with local insurance plans, which is considered in-network.
5. I understand it is my responsibility to inquire with my insurance plan on how many visits of outpatient physical therapy I am allowed per year if the office is not able obtain this information.

Precautions - Pregnant women, elderly persons with any heart disease, diabetes, high or low blood pressure should not enter the whirlpool without prior medical consultation and written permission from their Doctor.

No Exceptions - No person may enter the pool or whirlpool if suffering with any of the following; bowel or bladder incontinence, open/bleeding or draining wounds, or any communicable disease.

Observe the 15 minute time limit in the whirlpool. Long exposure may result in nausea, dizziness, or fainting. Enter and exit slowly.

Showering - Prior to entering the pool or whirlpool, each patient must shower and must be attired in appropriate swimwear. Please limit your shower time before and after your appointment as other people need to use the facilities.

Please avoid the use of baby powder and other substances that can spill on the floor and pose a safety risk, as well as unsightly conditions. Please pick up after yourself and place all clothing and other articles in a locker. DO NOT leave them in a changing room, on the floor, in the bathroom stall, or on the bench as other patients will be utilizing those areas.

I hereby give Physical Therapy Professionals, P.C. my consent to inform my case worker/manager, insurance
company, and doctor’s office of my physical therapy progress and share protected health information for
billing purposes. This includes phone conversations, faxes, progress reports, and doctor’s prescriptions.

Additional contact authorization may include notes/records and/or discussion of such. Information may include
patient progress, appointment times, scheduled appointment dates, etc.

I have the right to revoke this authorization at any time by sending written notification to Physical Therapy
Professionals, P.C. at the above address. I understand that a revocation is not effective to the extent that
Physical Therapy Professionals, P.C. has relied on the use or disclosure of the protected health information. I
also have the right to inspect or copy the protected health information to be used or disclosed as permitted
under Federal Law (or State Law to the extent the State Law provides greater access rights).

If you have failed to inform us that you have been treated by another facility within the last year for this injury, t is considered to be fraudulent, and you will personally responsible for any charges incurred.