Healthcare Studio Policies

HEALTHCARE STUDIO POLICIES

Client and Studio Identification

Studio Name:

Patient Information

Date of Birth:    Gender:

Insurance and Billing

I authorize the studio to bill the above insurance on my behalf and to release information necessary to process claims. I understand that I am financially responsible for any charges not paid by insurance, including co-payments, deductibles, and non-covered services.

Medical History

Consent for Treatment

I consent to evaluation and treatment by the studio providers. I understand that treatments may include physical assessment, manual therapy, therapeutic exercise, and other non-invasive techniques. I acknowledge that no guarantees have been made regarding the results of treatment.

Risks and potential complications have been explained to me, including but not limited to soreness, bruising, and increased pain. I understand I may withdraw consent at any time by informing studio staff in writing.

Payment, Cancellation, and No-Show Policy

Payment is due at the time of service unless other arrangements are made in advance. Accepted forms of payment are determined by the studio. Co-payments and outstanding balances are the responsibility of the patient.

Appointments canceled less than 24 hours before the scheduled time, and failures to appear without notice, may result in a cancellation or no-show fee. Repeated cancellations or late arrivals may result in termination of services.

Privacy and Use of Health Information (Authorization)

I acknowledge receipt of the studio's Notice of Privacy Practices. I authorize the use and disclosure of my protected health information for treatment, payment, and healthcare operations, including communications with other healthcare providers and insurers as necessary for my care.

I understand I may revoke this authorization in writing at any time except to the extent action has been taken in reliance upon it. This authorization will remain in effect until the date specified in the Authorization Expiration field or until revoked in writing.

Photography, Recording, and Telehealth

The studio may take clinical photographs or recordings for the purpose of treatment documentation. No photographs for marketing or social media will be used without separate written consent. Telehealth services may be provided when clinically appropriate; the patient consents to remote evaluation and acknowledges potential limitations of telehealth.

Acknowledgments and Agreements

By checking the boxes below and signing, I acknowledge that I have read, understand, and agree to the studio policies and authorizations described above. I certify that the information I have provided on this form is accurate to the best of my knowledge.

I consent to evaluation and treatment as described in this document.

I authorize submission of claims to my insurer and accept financial responsibility for unpaid balances.

I acknowledge receipt of the studio's Notice of Privacy Practices and authorize release of health information for treatment, payment, and operations.

I understand and accept the payment, cancellation, and no-show policies stated above.

Patient Signature

If signing as legal guardian or representative, indicate relationship to patient in the Relationship field below.

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