Healthcare Studio Policies Guide

HEALTHCARE STUDIO POLICIES GUIDE

Patient Information

Date of Birth:    Gender:

Primary Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Medical History

Primary Care Physician:    Phone:

Services, Risks, and Consent

Service to be provided:

I acknowledge that the studio will provide professional healthcare services appropriate to the service described above. I understand that all treatments carry potential benefits and risks, which may include temporary soreness, bruising, allergic reaction, or other adverse events depending on the modality provided. The provider has discussed anticipated benefits, likely results, and alternative options.

I have the right to withdraw consent to treatment at any time by providing written notice to the studio. Withdrawal of consent does not relieve me of financial responsibility for services already rendered.

I acknowledge that risks, benefits, and alternatives have been explained and I consent to the service listed above.

Appointments & Cancellation Policy

Appointments are reserved for each patient. The studio requires at least 24 hours' notice for cancellations. Late cancellations or no-shows may be subject to a cancellation fee equivalent to a portion or the full session fee as stated by studio policy.

I have read and agree to the studio's appointment and cancellation policy and understand applicable fees for late cancellation or no-show.

Fees, Billing, and Payment Responsibility

I understand that I am financially responsible for all charges for services provided by the studio whether or not covered by my insurer. Insurance billing will be submitted as a courtesy when requested, but ultimate responsibility for payment remains with the patient or guarantor.

I accept financial responsibility for services and any fees, co-payments, deductibles, or balances not covered by insurance.

Privacy Practices & HIPAA Acknowledgment

The studio maintains privacy protections for personal health information in accordance with applicable law. By signing below I acknowledge receipt of the studio's privacy practices and understand how my information may be used for treatment, payment, and health care operations.

I acknowledge receipt of the studio's privacy practices and authorize use of my protected health information for treatment and billing purposes.

Release of Medical Records / Authorization

I authorize the studio to release medical information to my insurer, other providers, or designated individuals as necessary for care coordination, billing, and payment. This authorization includes release of treatment records, billing records, and limited clinical notes unless specifically restricted below.

Expiration Date of this Authorization:

I authorize release of my medical records as described above. I understand I may revoke this authorization in writing except to the extent action has already been taken based on this authorization.

Additional Consents & Acknowledgements

I consent to receive care and procedures as deemed necessary by the studio provider.

I authorize the studio to submit claims to my insurance carrier and to provide any necessary information for payment.

I consent to the use of photographs or video for clinical documentation, quality assurance, or treatment planning. I understand any other use will require separate written consent.

Acknowledgment and Agreement

By signing below I certify that the information I have provided is accurate to the best of my knowledge, I have read and understand the studio policies contained in this document, and I agree to comply with these policies. I further acknowledge that I have had the opportunity to ask questions and receive answers about these policies and the care to be provided.

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