Vail Physical Therapy

Notice of Information Practices Policies and Procedures

1. CONSENT TO REHABILITATION PROCEDURES: The undersigned consents to the procedures which may be performed during this and future physical therapy visits that are performed by Vail Physical Therapy. I/We consent to examination, therapy procedures and therapy care given to the patient by or under the supervision of the physical therapist and have been informed of my rights. I/We have read over Vail Physical Therapy’s Consent to Treat and agree to treatment.
2. FINANCIAL AGREEMENT: The undersigned agrees whether he/she signs as agent or as patient, that in consideration of the services to be rendered to the patient, he/she hereby individually obligates himself/herself to pay the account of Vail Physical Therapy in accordance with the regular rates and terms of Vail Physical Therapy. All accounts are handled by an independent billing company, including billing, collections and all other matters relating to the account. I/We understand that I am financially responsible to Vail Physical Therapy for any/all expenses incurred, including those not covered by or paid for by my insurance company, as well as any collection/attorney/filing fees incurred in trying to collect payment. My signature authorizes payment of any insurance benefits to the supplier of services.
3. CANCELLATION POLICY: The undersigned agrees to a fee of $50.00 for a late canceled or missed appointments.Any further late canceled appointments will result in removal from future appointments and to be placed on Same Day Appointment Bookings only.
4. HIPAA POLICY: I have been given a copy of Vail Physical Therapy’s HIPAA and Privacy Policy and have therefore
   been advised of how health information about me may be used and disclosed by Vail Physical Therapy and how I may obtain access to and control this information.