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I authorize Valerie C. Wondra, PT and/or Move2Play Pediatric Physical Therapy or any entity doing business with Valerie C. Wondra, PT and/or Move2Play Pediatric Physical Therapy, to verify the benefits of our insurance and email us the benefit details.
I authorize Valerie C. Wondra, PT and/or Move2Play Pediatric Physical Therapy to bill my insurance company directly for the covered portion of charges, and I authorize payment of medical benefits directly to Valerie C. Wondra, PT and/or Move2Play Pediatric Physical Therapy
I authorize Valerie C. Wondra, PT and/or Move2Play Pediatric Physical Therapy to release medical or other information necessary to process this claim.
I understand that the verified estimation of benefits is provided as a courtesy, and does not guarantee coverage. I realize that I am ultimately responsible to know my level of coverage.
Valerie C. Wondra, PT and/or Move2Play Pediatric Physical Therapy will submit claims to my health insurance company. I am responsible for payment of my deductible, co-insurance or co-payment, and any charges not reimbursed by my insurance carrier.
It is my responsibility to inform Valerie C. Wondra, PT and/or Move2Play Pediatric Physical Therapy of any and all changes of insurance coverage during the course of treatment. Failure to do so may result in denial of coverage by my insurance company. If my insurance changes, Valerie C. Wondra, PT and/or Move2Play Pediatric Physical Therapy will bill my new insurance company, but there is no guarantee they will cover the services.
Valerie C. Wondra, PT and/or Move2Play Pediatric Physical Therapy uses a billing company to process claims and payments. The billing company is of our choice and its employees will have access to protected patient information. This is for the purposes of providing insurance companies with needed information to process claims. Your initials indicate your permission to share protected patient information in order to process payments on your child’s behalf.
I hereby consent to such treatment procedures and patient care which, in the judgment of my therapist and/or physician, may be considered necessary or advisable while a patient as Valerie C. Wondra, PT and/or Move2Play Pediatric Physical Therapy.
Physical therapy is a patient care service that is provided in order to manage a wide variety of conditions. Services are provided to individuals of all ages regardless of gender, color, ethnicity, creed, national origin, or disability.
The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis and intervention by use of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum potential within their capabilities and to accelerate convalescence and reduce the length of functional recovery. All procedures will be thoroughly explained to you before you are asked to perform them.
Response to physical therapy intervention varies from person to person; hence, it is not possible to accurately predict your response to a specific modality, procedure, or exercise protocol. Valerie C. Wondra, PT and/or Move2Play Pediatric Physical Therapy does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for. Furthermore, there is a possibility that the physical therapy treatment may result in aggravation of existing symptoms and may cause pain or injury.
It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns. It is your right to ask your physical therapist about the treatment they have planned based on your individual history, physical therapy diagnosis, symptoms, and examination results. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment.
I have read this consent form and understand the risks involved in physical therapy and agree to fully cooperate, participate in all physical therapy procedures, and comply with the established plan of care. I authorize the release of my medical information to appropriate third parties.
I hereby release, discharge and acquit Valerie C. Wondra, PT and/or Move2Play Pediatric Physical Therapy, it’s agents, representatives, affiliates, employees or assigns of and from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive or allow emergency and or medical services, including but not limited to ambulance service, Emergency Medical Technician, physician or urgent care services.
As of July 1, 2013 according to the State of Kansas Physical therapy Practice Act, Statue 65-2921 states that patients may refer themselves to a physical therapist without a referral from their physician or other health care provider. As stated in this statute it is our responsibility to inform you that at the conclusion of an initial evaluation, we will not be providing you with a medical diagnosis but rather a physical therapy diagnosis and appropriate physical therapy goals to work towards in future physical therapy visits. In the event that you do not make measurable progress towards the physical therapy goals set by you and your physical therapists within 10 visits or 15 business days after your second visit with your physical therapist we are then required by law to receive a referral from an appropriate “licensed health care practitioner” to continue your physical therapy plan of care. A “licensed health care practitioner” means a person licensed to practice medicine and surgery, a licensed podiatrist, a licensed physician assistant or a licensed advanced practice registered nurse working pursuant to the order or direction of a person licensed to practice medicine and surgery, a licensed chiropractor, a licensed dentist or licensed optometrist in appropriate related cases
Initial or check all that apply:
I hereby acknowledge that I have received a copy of this Clinic’s Notice of Privacy Practices.
Please note that once you have scheduled an appointment with us, it means that we have reserved time in our schedule exclusively for you. If you cancel your appointment less than 24 hours before it is scheduled to take place, you will be subject to an administrative fee of $30 for a regular appointment or $60 for an evaluation appointment. This fee is NOT billable to insurance companies and will be directly to the credit card we have on file.
To avoid missed appointments please make sure we have an updated email and/or phone number for reminders of your scheduled appointments.
Should you miss 3 visits in one quarter, due to reasons other than illness, it will be considered that you are not in adherence or compliance with your plan of care and will be discharged from treatment. Your primary physician will be notified, and you will be given names of 3 like professionals, upon request, for your future use, should you decide to begin therapy services elsewhere.
If signing on a computer, your printed name following this consent will function as your signature. Thank you for choosing Valerie C. Wondra, PT and Move2Play Pediatric Physical Therapy for your child’s therapy services.
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