Healthcare PT Contract

HEALTHCARE PHYSICAL THERAPY SERVICES AGREEMENT

This Physical Therapy Services Agreement (Agreement) is entered into between Clinic Name: and Patient Name: . Effective Date: .

Patient Information

Insurance & Billing

Financial Responsibility: The undersigned patient accepts financial responsibility for payment of services rendered that are not covered by insurance, including co-payments, co-insurance, non-covered services, denials, or amounts applied to deductible. Fee per therapy session: $ . Patient copay amount: $ .

Medical History

Check any of the following that apply:

Cardiac condition
Diabetes
Pregnant or trying to conceive
Implanted medical device (e.g., pacemaker)

Scope of Services & Treatment Plan

Description of Services: The Clinic will provide physical therapy evaluation and treatment, which may include but is not limited to therapeutic exercise, manual therapy, neuromuscular re-education, gait training, modalities (heat, cold, electrical stimulation), and patient education. Describe specific treatment goals and primary areas of focus:

Risks and Benefits: Patient acknowledges that physical therapy carries potential risks including but not limited to increased pain, fatigue, muscle strain, joint sprain, cardiovascular events, and allergic reaction to therapeutic agents. Benefits may include reduction of pain, improved function, increased strength and mobility. The treating therapist will explain anticipated risks and reasonable alternatives prior to treatment.

Patient acknowledges the right to refuse any procedure, to ask questions, and to withdraw consent at any time without jeopardizing the ability to seek future treatment. Withdrawal of consent for treatment does not relieve patient of financial obligations for services already rendered.

Appointments, Cancellation & No-Show Policy

Appointments are scheduled for a specific time. Cancellation less than hours prior to the appointment or failure to attend without notice may result in a charge of $ . Repeated no-shows may result in discharge from services.

HIPAA & Privacy Authorization

Patient acknowledges receipt of the Clinic's Notice of Privacy Practices and authorizes the use and disclosure of protected health information for treatment, payment, and healthcare operations as permitted by law. The patient authorizes release of medical records to referring providers and to payors for billing and utilization review purposes.

Authorization to communicate appointment reminders and limited clinical information via phone or electronic messaging: Yes, contact me No, do not contact

Authorization & Release

I authorize the Clinic and its staff to provide physical therapy services as described above. I authorize the release of information necessary for payment and care coordination. I agree to pay all charges not covered by insurance. I release the Clinic and its employees from liability for ordinary negligence to the extent permitted by law, except for willful misconduct or gross negligence.

This authorization shall remain in effect until , unless earlier revoked in writing.

Acknowledgments

By signing below, I certify that the information I have provided is accurate to the best of my knowledge, that I have read and understand this Agreement, and that I consent to the treatment and terms set forth herein.

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