CONSENT FOR CARE AND TREATMENT: I hereby agree and give my consent to R|O|C Physical Therapy, PLLC to perform the evaluation and treatment procedure that are deemed necessary by my physician and therapist in the treatment of my condition. I further authorize R|O|C Physical Therapy, PLLC to furnish appropriate agencies for the purpose of billing, any information acquired during the course of my treatment and to send me notices and reminders of my appointments via email or text messaging. I am assigning my therapy benefits to R|O|C for the services in which I receive and authorize my insurance carrier to make payments to R|O|C on my behalf. R|O|C reserves the right to seek reimbursement from any and all of your insurance carriers regardless of whether you provide us with their contact information, unless you instruct us to bill you directly. R|O|C is HIPPA compliant regarding information sharing policies. I understand that the benefits and risks to all interventions will be explained and that the patient holds the final judgment in such matters.

MEMBER DIRECT PAYMENT NOTIFICATION: Arizona state constitution permits you to pay a healthcare provider for health care services directly. If you have any active health insurance coverage, please review the provider’s policies regarding payment before you make any arrangements to pay directly.

AUTHORIZATION TO PAY: I hereby authorize insurance payment directly to R|O|C Physical Therapy, Billing Department, 5656 South Power Rd. Ste 139 Gilbert, AZ 85295 for medical services rendered. I understand that I am financially responsible for the charges not covered by my insurance. In the event of default, I promise to pay collection costs and reasonable fees as may be required to obtain collection of this account.

ATTENDANCE AGREEMENT: Due to the nature of physical therapy, your progress and full recovery are dependent on both our experienced physical therapists, and your active participation and commitment to your appointments. We ask as a courtesy to other patients looking to schedule and our staff and therapists that if you need to cancel your appointment, please try to contact R|O|C Physical Therapy, PLLC at least one day prior to your appointment.

WORKERS COMPENSATION PATIENTS: We are required to inform your Workers’ Compensation Adjuster and/or Rehabilitation Manager of all missed or canceled appointments. It is also required that all missed visits be rescheduled.

AUTHORIZATION TO COMMUNICATE ELECTRONICALLY: I understand that authorized personnel (including my physical therapist) from R|O|C Physical Therapy, PLLC may communicate with me regarding scheduling/ appointments, the treatment provided, home exercise programs, and educational/informative content as it relates to my condition. I understand that my protected health information (PHI) will not be communicated electronically. I understand that I have the opportunity to opt-out of future communications at any time using the “unsubscribe” option on any communication via text or email. By my signature below, I certify that I have read, understand, and fully agree to each of the statements in this document.

I have read and fully understand R|O|C Physical Therapy’s Notice of Information Practices. I understand that R|O|C Physical Therapy may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment, and administrative operations if I notify the practice. I also understand that R|O|C Physical Therapy will consider requests for restriction on a case by case basis. I hereby consent to the use and disclosure of my personal health information for purposes as noted in ROC Physical Therapy’s Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.

This notice describes how medical information about you may be used or disclosed and how you can get access to information. Please review it carefully.

R|O|C PHYSICAL THERAPY, PLLC LEGAL DUTY: R|O|C Physical Therapy, PLLC is required by law to protect the privacy of your personal health information, provide this notice about our information practices, and follow these practices that are described herein.

USES AND DISCLOSURES OF HEALTH INFORMATION: R|O|C Physical Therapy, PLLC uses your personal health information primarily for treatment; obtaining payment of treatment; conducting internal administrative activities, and evaluating the quality of care that we provide. For example R|O|C Physical Therapy, may use your personal health information to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you.

R|O|C Physical Therapy, PLLC may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law.

In any other situation, R|O|C Physical Therapy’s policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization through a written statement to stop future disclosures at any time.

R|O|C Physical Therapy, PLLC may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the clinic and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time.

PATIENT’S INDIVIDUAL RIGHTS You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate information or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes.

You may also request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. R|O|C Physical Therapy, PLLC will consider all such requests on a case by case basis, but the practice is not legally required to accept them.

CONCERNS AND COMPLAINTS If you are concerned that R|O|C Physical Therapy may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact us, you will not be retaliated against for filing a complaint.

WellRx Questionnaire