CONSENT TO SERVICES AND AGREEMENT
I, the undersigned, hereby agree as follows:
1. Physical Therapy Treatment. I give my consent to have POSTUREWORKS PHYSICAL THERAPY (i.e., Kim M. Finklestein Physical Therapy, Inc. d/b/a Postureworks, “Postureworks”) provide physical therapy, consultation, personalized instruction, Redcord treatment, and hands-on manual treatment (collectively referred to as “physical therapy”). I will provide all information necessary to acquire initial orders from my physician as needed, and understand that I may be required to acquire additional orders/prescriptions (if necessary). I have discussed with my physician my decision to proceed with physical therapy at Postureworks, and my physician has (i) confirmed that I do not have any physical or psychological conditions that would advise against or prohibit such physical therapy, (ii) explained the potential risks of physical therapy, and (iii) discussed the medical, surgical, or pharmacological alternatives to physical therapy. I understand that physical therapy may increase my current level of pain or discomfort or aggravate an existing injury or condition. If any such increased pain and/or discomfort does not subside within a reasonable time period, I will immediately contact my physician and inform my physical therapist.
2. No Warranty. Postureworks does not make and has not made any promises or guarantees regarding whether physical therapy will improve or cure my condition, symptoms or pain/discomfort.
3. Cooperation. I have provided or had my physician provide all information (e.g., medical reports, imaging reports, etc.) needed for Postureworks to evaluate my condition and make a recommendation for a physical therapy plan (and will continue to provide updated information regarding my condition that may affect my treatment plan). I consent to such physical therapy plan and agree to cooperate fully, to participate in all physical therapy care and safety procedures, and to comply with the plan of care as it is established. I also recognize that physical therapy care may involve the touching of my body by the physical therapist and that full or partial disrobing may be required to facilitate such care, all of which is expressly consented to by me. I will immediately notify Postureworks if I have a pacemaker, have had any surgical procedure in the past or undergo any surgical procedure while I am receiving therapy or services from Postureworks. Also, I will immediately notify Postureworks if I am pregnant, become pregnant, believe I may be pregnant or if I am trying to get pregnant; and if I am or become pregnant, I will immediately discuss with my physician the potential benefits and risks of physical therapy treatment relevant to my pregnancy (and will immediately inform my physical therapist of my physician’s advice or recommendation).
4. Release of Medical Records. Postureworks is authorized to notify my physician(s) (and/or surgeon(s), if applicable) and inform them that I am receiving physical therapy treatment, discuss my physical therapy and all related information, and receive or send medical information regarding my medical condition and physical therapy.
5. Patient Financial Responsibilities.
(A) PAYMENT IN FULL IS DUE IN ADVANCE OF ALL SERVICES. It is my responsibility to prepay the entire cost of a session at the time of scheduling an appointment (s), including all copayments, co-insurance, and deductibles. Concurrent with entering into this CONSENT FOR SERVICES AND AGREEMENT, I agree to secure my account with Postureworks with a credit/debit card (and agree that Postureworks may charge my credit/debit card in accordance with its Cancellation Policy). I have the option to pay for such sessions by cash, check, credit/debit card or by the purchase of a prepaid package of sessions. (I understand there will be a $25 charge for any returned check). The duration of each session is 50 to 55 minutes (although I can choose to terminate a session before the full 50 to 55 minutes, but there is no refund or discount for the unused time); and sessions cannot be divided into shorter time periods. If I purchase a prepaid package of sessions, it must be paid for in full prior to the first session; and I understand and agree that (i) it is entirely non-refundable and is non-transferable (in whole or part) and (ii) it must be used within one (1) year of the date of purchase or any unused sessions will automatically expire.
(B) HEALTH BENEFIT COVERAGE. I understand and agree it is my sole responsibility to know and understand the details of my health benefit coverage, and Postureworks makes no representation, warranty or guarantee about my coverage or benefits or cost-sharing responsibility. I understand and agree it is my responsibility to contact my health benefit coverage plan prior to any service at Postureworks to become familiar with my benefit coverage and allowed amounts applicable to Postureworks’ services, if any.
Postureworks is a Medicare provider. As of July 1, 2020, Postureworks submits bills on a patient’s behalf only if the patient is a Medicare beneficiary as described above. Postureworks does not accept any HMO benefits or Medicaid coverage. In the future, Postureworks may, at its sole discretion, submit bills to other health benefit coverage, even if out-of-network; however, patients hereby acknowledge and agree they understand Postureworks does not guarantee in any way that an out-of-network plan will pay or reimburse the patient for any portion of the amounts they pay directly to Postureworks.
I understand and agree, if I have a PPO insurance plan, Postureworks will collect the estimated co-payment, co-insurance, and deductible amounts due in advance of the visit. However, I understand Postureworks does not guarantee in any way that my plan will pay or reimburse me for any portion of the amounts I pay to Postureworks or that the estimated amounts are the sole amounts my plan will designate as my responsibility and I therefore may owe additional amounts.
When permissible, in the event my health plan determines a service to be “non-covered,” Postureworks will bill me, and payment is due upon receipt of that statement. Any amount not paid by my plan within 30 days will be billed to me. If Postureworks is out-of-network with my plan I understand and agree I must pay for my service in full in advance of my treatment.
(C) CANCELLATION POLICY. We understand that scheduling issues come up. However, because of COVID safety precautions limiting our occupancy and the demand for our scanning and rehabilitation technologies, we are unable to accommodate any cancellation with less than 48 hours notice. As such, you will be charged in full or a session will be deducted from your package. Monday and Tuesday appointments must be cancelled by the previous Friday to avoid a late cancellation fee.
6. Miscellaneous. This document shall be construed (both as to validity and performance) and enforced in accordance with the substantive laws of the State of California (notwithstanding any choice of law principles, statutes or rules to the contrary). Any action or proceeding arising in connection with or relating to the matters covered by this CONSENT FOR SERVICES AND AGREEMENT (including claims relating to or arising from the physical therapy or other services provided by Postureworks) shall be litigated only in the state and federal courts located in the City of Los Angeles, State of California (and such courts shall have in personam jurisdiction and venue over such party for the purpose of such litigation), and I hereby expressly and knowingly waive any right I may have to assert the doctrine of forum non conveniens or otherwise object to venue.
7. Consent for Wellness Services.
I understand the practice of physical therapy and the requirement for a physician’s prescription do not apply to a physical therapist when he or she is only providing wellness services to preserve a patient’s present level of function. I understand and agree that even if I begin my treatment with Postureworks under the order of a physician, once I reach the defined therapeutic goals in my treatment plan, Postureworks must accurately describe my status. When Postureworks determines there is no additional clinically significant functional progress expected to occur, but recommends continued treatment to maintain function and prevent regression, I understand my health benefit coverage will no longer apply and I agree to pay for such wellness services in full and in accordance with paragraph 5(B) above.
By signing below, I acknowledge that I have read and understand this CONSENT TO SERVICES AND AGREEMENT.