Healthcare Physiotherapy Contract

HEALTHCARE PHYSIOTHERAPY CONTRACT

Parties and Effective Date

Clinic Name:

Clinic Address:

Patient Name:

Effective Date:

Patient Information

Insurance Information

Medical History (Relevant)

Scope of Services

The Clinic shall provide physiotherapy evaluation and treatment consistent with the patient's presenting condition and the Clinic's standard of care. Scope includes therapeutic exercise, manual therapy, modalities, functional training, and home exercise instruction. Specific treatment goals and maximum number of sessions:

Fees, Billing and Assignment

Fee per session (estimated): $. Patient is responsible for co-payments, deductibles, and any non-covered services. Payment is due at the time of service unless otherwise agreed in writing.

Assignment of benefits: I authorize the Clinic to bill my insurer and to release any medical information necessary to process claims. I assign benefits payable for services to the Clinic: Yes

If insurance denies payment, I accept financial responsibility for services rendered. Estimated outstanding balance policy:

Cancellation and No-Show

Appointments must be cancelled at least hours prior. Late cancellations or no-shows may incur a fee of $. Repeated missed appointments may result in termination of treatment.

Risks, Benefits and Consent to Treatment

I acknowledge that physiotherapy and related procedures have potential risks, including but not limited to increased pain, aggravation of pre-existing conditions, muscle or joint strains, allergic reaction to topical agents, fainting, and rare complications. Potential benefits include decreased pain, improved function, and reduced disability.

I have received an explanation of the proposed treatments, have had the opportunity to ask questions, and voluntarily consent to physiotherapy and related care. I understand I may withdraw consent at any time by notifying the treating clinician.

I acknowledge that neither results nor guarantees have been promised: I acknowledge

Privacy and HIPAA Acknowledgment

I acknowledge receipt of the Clinic's Notice of Privacy Practices and consent to the Clinic's use and disclosure of my protected health information for treatment, payment, and healthcare operations, as described in the notice.

Acknowledgment of Privacy Notice: I acknowledge

Authorization and Release

Authorization for release of records to referring providers or payors: Authorized

This contract constitutes the entire agreement between the Patient and the Clinic with respect to physiotherapy services. Any amendment must be in writing and signed by the patient and an authorized representative of the Clinic.

Dispute Resolution and Governing Law

Any dispute arising under this agreement will be governed by the laws of the state where services are rendered. Parties agree to attempt good faith resolution through negotiation prior to initiating formal dispute resolution.

Additional Patient Responsibilities

Patient agrees to participate actively in care, follow home exercise programs, report changes in health status, and notify the Clinic promptly of insurance changes. Failure to follow prescribed program may limit effectiveness of treatment.

Authorization Expiration

This authorization to treat and to release information is valid until: or until revoked in writing by the Patient, whichever occurs first.

Acknowledgment and Certification

By signing below, I certify that the information provided on this form is complete and accurate to the best of my knowledge. I consent to the provision of physiotherapy services described above and accept financial responsibility as stated.

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