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Patient Agreement

Welcome to POST Physical Therapy!

Please read and sign at the bottom.

We strive to provide our patients with excellent service and quality care. We will recommend treatment and set goals for you. In order to reach those goals, appointments must be attended. We would appreciate 24‐hour notice if you need to cancel an appointment so we can fill your appointment time. If you do not give 24 hours notice or you fail to show for a scheduled appointment, a $50 fee will be billed to you. Our number is 617‐860‐6430. If you miss 3 consecutive appointments, we may have to notify your physician and will require a new referral in order to continue your treatment.

Our staff will contact your insurance company to verify your physical therapy benefits and let you know what your responsibility will be at the time of service.

We encourage you to call your insurance provider to discuss your coverage and what your financial obligations may be.

Please speak with our Front Desk Specialist if you have any questions regarding your appointments, insurance, financial responsibilities, or any other issues.

Please speak with your therapist if you have any questions regarding your Physical Therapy treatment. We thank you for choosing POST Physical Therapy and we look forward to working with you and helping you.

Patient Information

Patient Location:

Is the patient under 18 years of age?:

Appointment Reminders:
Type of Reminder:

Email tips and offers:
Legal Sex:

Have you had Physical Therapy this calendar year?:

How did you hear about us?
Doctor:
Social Media:
Online Review:
Other:
Referred by:
Other referral:
Trainer:
Other source:
Have you had Physical Therapy this calendar year?:
How many visits and when?

Physician Information

Do you have the required PT Order?

Insurance Information

Is this a motor vehicle or workman's comp claim?:

Is subscriber's address the same as patient?:

Secondary Insurance Information

Do you have Secondary Insurance?*

Patient Details

Did you receive Physical Therapy for this?:

Has your condition been getting:
What are your current medications?:
Mark the number that best corresponds to your pain below:
Your pain at its most painful:
Your pain at its least painful:
Please describe the nature of your pain (checked all that apply):

What decreases pain/makes your condition better?:
What increases pain/makes your condition worse?:
Previous Medical Intervention:

Do you have additional documentation?
Documentation:

ASSIGNMENT / INSTRUCTION FOR DIRECT PAYMENT TO HEALTH PROVIDER

I hereby instruct the insurance company/companies to pay by check made out to and mailed directly to POST Physical Therapy for professional or medical expenses allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered.

THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY.

This payment will not exceed my indebtedness to the above-mentioned assignee By signing below I have agreed to pay, in a current manner, any balance of said professional fees for non-covered services and/or fees, over and above the insurance payment or as required by my insurance policy. I understand that POST Physical Therapy complies with HIPAA and will protect my Protected Health Information (PHI) and will use it as allowable by law in the treatment, billing, and collection pertaining to my care until my case is closed and full payment is received. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or an attorney for the purpose of securing payment under this policy of insurance or to any Medical Provider associated with my case to effectively treat me. The authorization is in effect until 90 days from the date the last bill is collected.

HIPAA REGULATIONS

A photocopy of this Assignment shall be considered effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney for the purpose of securing payment under this policy of insurance under the HIPAA guidelines.

CONSENT TO TREATMENT AND DISCLOSURE OF PATIENT INFORMATION

I hereby authorize the professional staff at POST Physical Therapy to examine and treat me with physical therapy for the injury I have been referred here for or referred me to. I also authorize my protected health information to be disclosed to my insurance company (s), my doctor and /or other healthcare providers as well as my attorney.

PATIENT'S FINANCIAL RESPONSIBILITY

By signing below I authorize benefit payments directly to POST Physical Therapy that would otherwise be payable to me. I authorize POST Physical Therapy to securely store my credit card information, and only charge it should I have a co-payment, cancellation fee, deductible, coinsurance, or any leftover balance from a processed claim.

I understand that it is my sole responsibility to notify you in a timely manner of any change to the information I have provided. If I do not cancel or reschedule an appointment without giving at least 24 hours notice I may be charged a fee. If a check I provide bounces I understand there is a $50 fee. POST strongly suggests that I the patient contact my insurance company to verify benefit information. However, POST assumes no liability for any misunderstanding or errors made by my insurance carrier in regards to the information received and what my ultimate responsibility is for visits.

If no or incorrect insurance information is provided by the patient, visits will be processed at the self-pay rate. POST expects payment at the time of service. A prescription for Physical Therapy from a physician is required.

REMINDER PHONE CALLS ARE A COURTESY AND SHOULD NOT BE RELIED UPON FOR KEEPING TRACK OF YOUR APPOINTMENTS.

Patient Bill of Rights

All patients should be guaranteed the following freedoms:

To seek consultation with the physician(s) of their choice;
To contract with their physician(s) on mutually agreeable terms;
To be treated confidentially, with access to their records limited to those involved in their care or designated by the patient;
To use their own resources to purchase the care of their choice;
To refuse medical treatment even if it is recommended by their physician(s);
To be informed about their medical condition, the risks and benefits of treatment and appropriate alternatives;
To refuse third-party interference in their medical care, and to be confident that their actions in seeking or declining medical care will not result in third-party-imposed penalties for patients or physicians;

To receive full disclosure of their insurance plan in plain language, including:

CONTRACTS: A copy of the contract between the physician and health care plan, and between the patient or employer and the plan;
INCENTIVES: Whether participating physicians are offered financial incentives to reduce treatment or ration care;
COST: The full cost of the plan, including copayments, coinsurance, and deductibles;
COVERAGE: Benefits covered and excluded, including availability and location of 24-hour emergency care;
QUALIFICATIONS: A roster and qualifications of participating physicians;
APPROVAL PROCEDURES: Authorization procedures for services, whether doctors need approval of a committee or any other individual, and who decides what is medically necessary;
REFERRALS: Procedures for consulting a specialist, and who must authorize the referral;
APPEALS: Grievance procedures for claim or treatment denials;
GAG RULE: Whether physicians are subject to a gag rule, preventing criticism of the plan.

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Signed by POST PT Luke Ferdinands
Signed On: January 19, 2023

Timestamp

Audit

March 23, 2018 6:06 pm EDT

Patient Agreement Uploaded by POST PT Luke Ferdinands - info@postpt.com IP 96.237.59.139

September 16, 2021 2:04 pm EDT

POST PT - info@postpt.com added by POST PT Luke Ferdinands - info@postpt.com as a CC'd Recipient Ip: 173.9.65.41