I consent to treatment rendered by ProHealth Physical Therapy and Pilates Studio as ordered or approved by my physician. I agree to participate in ProHealth Physical Therapy and Pilates Studio’s program to the best of my ability to facilitate a rapid and full recovery.

I consent to having my picture taken for objective analysis of my condition. This information will be used solely for the purpose of education of myself for my condition and to compare pre and post treatment outcomes. Any other use of this information will require my written consent.

I understand that some increase in pain may be normal. I must determine how much pain increase is acceptable to me, and I may be asked to describe any pain using a Visual Analog Scale. I will not be asked to perform activities that increase my pain to a level that is unsafe or undesirable to me. I will be asked to perform activities, but will not be forced to perform any activity that I believe unsafe. I will be informed if I’m seen doing anything unsafe or that jeopardizes my recovery.

I, a patient of ProHealth Physical Therapy and Pilates Studio, give my express permission for ProHealth Physical Therapy and Pilates Studio to discuss the information I have specifically indicated below with the following individuals:

I am responsible for notifying this office, in writing, of any changes to this authorization to disclose my personal health information.

As a way to improve communication and prioritize convenience for patients, ProHealth Physical Therapy and Pilates Studio utilizes text messaging and email to communicate appointment reminders. I understand that I am not required to authorize the use of text messaging or email in order to receive services from ProHealth Physical Therapy and Pilates Studio.

 

If, so indicated above, I consent to receiving appointment reminders as outlined above. I understand there are risks associated with receiving communications via text message and email because these types of communications are not always secure – emails and text messages can be intercepted. I understand that have the right to revoke this consent at any time by notifying the facility.

I acknowledge that I have read, understand, and agree to all of the terms above.

ProHealth Physical Therapy and Pilates Studio will file my insurance claims as a courtesy, and I understand that any quoted benefits provided at the time of service are not a guarantee of payment. I assign all insurance benefits to be paid directly to ProHealth Physical Therapy and Pilates Studio. I understand that I am ultimately responsible for the charges incurred for my services at ProHealth Physical Therapy and Pilates Studio that are not covered by my insurance.

I understand that additional information may be required of me to assist ProHealth Physical Therapy and Pilates Studio in filing such claims, and I agree to provide this information as requested, including by not limited to:

o Social Security Number

o Date of Birth

o Copy of Insurance Card (for commercial filing and/or workers’ compensation)

o Name of employer, employer address, phone number and contact person

o Auto Insurance

As a standard practice, ProHealth Physical Therapy and Pilates Studio collects all expenses that are the responsibility of the patient at the time of service. This request for payment will include any deductible, co-pay and coinsurance amounts that apply to my visit. I understand that as a courtesy, ProgressiveHealth of Indiana will bill my insurance directly for the services I receive, but this is not a guarantee that my insurance will pay for services rendered or materials received. It is my responsibility to know my insurance benefits and coverage.

In some cases, the amount of charges is an estimate based upon information provided directly by my insurance company regarding my particular plan and eligibility and the procedures performed. However, the exact amount of all charges may not be known at the time of service as my insurance may process differently than anticipated. It is possible that additional expenses that are my responsibility may be reflected on my final statement. In such a case, the payment collected at the time of service serves as a deposit towards my final balance. Additionally, any overpayment will be promptly refunded to me after all claims have been processed by all applicable payers.

In the event that there is a past due balance on my account, it will be submitted to a collection agency, and I agree to pay all attorneys’ fees and court costs incurred by ProHealth Physical Therapy and Pilates Studio in the collection of my account.

I understand that if I anticipate problems paying my portion of my bill, I should let the Front Office Coordinator know as soon as possible, so that payment alternatives may be discussed, should I qualify.

I authorize ProHealth Physical Therapy and Pilates Studio or its agents to contact me via manual or auto-dial telephone call in order to collect any amounts I may owe, including calls to my cell phone number, if I have provided that number. I also agree that any email address I have provided is my personal email address and I authorize ProHealth Physical Therapy and Pilates Studio or its agents to contact me via that email address.

I acknowledge that I have read, understand, and agree to all of the terms above.

We strive to provide not simply good, but absolutely the best care to our clients. We schedule our clients according to care plans that optimize their wellness outcomes. Making your appointment as scheduled is very important, not just for us, but for you. We are convinced that if you make your wellness a life priority, you will achieve not only a higher level of function, but a greater degree of happiness.

We have the most highly trained and experienced clinicians in the region. You are working with the best. Their services and time are in high demand, with waiting lists for many of their services. As you know, we attempt to schedule all new clients within 24-48 hours of their initial request for service. Thus, appointment time is a valuable commodity for both you and us.

If negative circumstances require you to cancel a scheduled appointment, we request that you do so at least 48 hours in advance. If you must cancel within 24 hours of your appointment or fail to show up for your appointment, a $25 fee will be applied to your account, which will be patient responsibility and is not billable to insurance. This facility also reserves the right to cease rescheduling new appointments due to habitual no shows or cancellations and reserves the right to discharge any patient who fails to give proper notice three consecutive times.

While we are not fond of the negative connotation of any cancellation policy, we believe such a policy is in the best interest of accommodating all of our clients who are dedicated to improving their wellbeing. When an appointment is made, it takes an available slot away from another client. No-shows and late-cancellations prohibit us from offering that slot to another client. We understand that situations such as medical emergencies occasionally arise when an appointment cannot be kept and adequate notice is not possible. These situations will be considered on a case by case basis. Thank you for your consideration.

I acknowledge that I have read and understand the Cancellation / No-Show Policy.

Click here for the Notice of Privacy and Practices

I have received a Notice of Privacy Practices from ProHealth Physical Therapy and Pilates Studio.