I authorize my referring provider to release my medical records to Alpine Physical Therapy for doucments related to my physical therapy diagnosis. A photocopy or fax of this document shall be considered as valid as the original. This release shall be in effect until revoked.
I hereby authorize Alpine Physical Therapy to use and/or disclose my health information, which specifically identifies me or which can reasonably be used to identify me, to carry out my treatment, payment, and healthcare operations.
I hereby acknowledge that I have received a copy of the Notice of Privacy Practices.
I hereby authorize payment of medical benefits billed to my insurance by Alpine Physical Therapy. I have listed all health insurance plans from which I may receive benefits. I hereby accept responsibility for payment for any services provided to me that is not covered by my insurance.
I authorize my treating physical therapist at Alpine Physical Therapy to provide treatment which they judge to be appropriate. I acknowledge that no representation or guarantees have been made to me as a result of the treatment of care.
To receive maximum benefit from your rehabilitation program, it is of utmost importance that you attend your therapy appointments consistently and that you follow your home instructions.
Please note: it is your responsibility to schedule your appointments in advance. If you are unable to keep your appointment, please notify us at least 24 hours before your scheduled appointment by calling your respective clinic. We have an answering machine on 24 hours a day if you call after hours. A no-show fee of $35.00 may be assessed for a missed appointment or a short-notice cancellation. You are subject to be discharged from our services after three missed appointments within a four-week period.
Your cooperation is appreciated. We look forward to working with you with the goal of optimal results from your rehabilitation program.