Healthcare Private PT Agreement

HEALTHCARE PRIVATE PT AGREEMENT

This Private Physical Therapy Agreement (the Agreement) is entered into by and between Provider Name: and Patient Name: on Agreement Date: . This Agreement sets forth the terms under which Provider will deliver private physical therapy services to Patient.

1. PATIENT INFORMATION

Date of Birth: Gender:

2. INSURANCE & BILLING

Patient Financial Responsibility: Patient agrees to pay all charges not covered by insurance, including co-payments, deductibles, and services denied by insurer. Provider will bill insurance as a courtesy if requested. If Provider is not authorized to bill Patient's insurer, Patient accepts full responsibility for payment at time of service.

3. SCOPE OF SERVICES

Frequency and Duration: Anticipated frequency: ; Anticipated duration: .

4. MEDICAL HISTORY

5. CONSENT TO TREATMENT; RISKS & BENEFITS

Patient hereby consents to the provision of physical therapy and related services by Provider. Patient acknowledges that the nature of the treatment, expected benefits, and reasonably foreseeable risks have been explained, including but not limited to increased pain, muscle soreness, bruising, aggravation of pre-existing conditions, and rare but serious complications. Patient has had opportunity to ask questions and understands that no guarantee of cure or particular result has been made.

Patient may withdraw consent at any time by providing written notice to Provider. Withdrawal of consent will not affect obligations for payment for services rendered prior to withdrawal.

6. CANCELLATION & NO-SHOW POLICY

Appointments cancelled with less than 24 hours' notice or failure to appear may be subject to a cancellation fee. Repeated cancellations or no-shows may result in termination of services. Patient agrees to notify Provider as soon as possible of inability to attend scheduled sessions.

7. CONFIDENTIALITY & HIPAA AUTHORIZATION

Patient acknowledges receipt of Provider's Notice of Privacy Practices and consents to the use and disclosure of protected health information for treatment, payment, and health care operations. Patient authorizes Provider to disclose PHI to the following individuals for scheduling, billing, or clinical communication:

Authorization Expiration Date: . Patient may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon it.

8. TELEHEALTH & ELECTRONIC COMMUNICATION

Patient consents to communication via telephone, secure messaging, and, if applicable, telehealth sessions. Patient understands that electronic communication is not fully secure and that certain risks exist. Patient authorizes Provider to send appointment reminders and billing notices via the following methods (check all that apply):

Phone call    Text message    Email

9. LIMITATION OF LIABILITY; INDEMNIFICATION

Provider will exercise professional skill and judgment in providing services. Provider's liability for any claim arising out of or relating to the services provided under this Agreement shall be limited to direct damages and shall not include consequential, incidental, or punitive damages. Patient agrees to indemnify and hold Provider harmless from claims arising from Patient's failure to disclose material medical information or failure to follow instructions.

10. TERMINATION

Either party may terminate this Agreement at any time with written notice. Termination does not relieve Patient of responsibility for payment of services rendered prior to termination.

11. ADDITIONAL ACKNOWLEDGMENTS

Patient certifies that all information provided on this form is true and complete to the best of Patient's knowledge. Patient authorizes Provider to obtain and release medical information as necessary for treatment and payment purposes. Patient agrees to comply with Provider policies and acknowledges receipt of a copy of this Agreement upon request.

12. ACKNOWLEDGMENT OF CONSENT

By signing below, Patient (or legal guardian) acknowledges understanding of and agreement to the terms set forth in this Agreement, including consent to treatment, financial responsibilities, privacy practices, and communication preferences.

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