Online Intake Form

Enchantment Physical Therapy

Rio Rancho Tel# : (505) 896-0835 Gallup Tel#: (505) 863-4199
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Is this a WORK injury?*

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Is this an AUTO injury?*

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Cancellation and No Show Policy
We understand that unplanned issues can come up and you may need to cancel an appointment. If that happens, we respectfully ask for scheduled appointments to be canceled at least 24 hours in advance.

When a patient doesn't keep their appointment as scheduled, three people are hurt:
1. You, because you won't get the treatment you need as prescribed by your physician.
2. Another patient who could have been scheduled for treatment if there had been proper notice.
3. The therapist, who now has a space in their schedule since the time was reserved for you personally.
There will be a fee of $20.00 assessed if we do not receive a 24-48 hour call to cancel an appointment.

This will not be covered by insurance but will have to be paid by you personally.

It is your responsibility, when you contact us, to have an alternative time in mind that will ensure you get the full treatment for that week. In some cases, this may not be possible, but we will make every effort to accommodate your reschedule request.

Please understand that your pain may increase and decrease as your course of treatment progresses.
At times you may:
- Feel worse and think the treatment is not working or making you worse
- Feel better and don't think you need to come anymore
Neither of these is a legitimate reason to not come.

You may need to be seen by a different therapist than one that normally treats you if you rearrange your appointment. All of our therapists are experienced professionals, and they will study your patient chart, so you will be in good hands. IHS/CHS, NM Medicaid patients please know that you can take advantage of your scheduled appointments, your physical therapy treatment is paid full coverage with no copay or deductible.

Thank you for being a valued patient and for your understanding cooperation. This policy will enable us to open otherwise unused appointments to better serve the needs of all patients.
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Acknowledgement of Privacy Rights
My signature confirms that I have been informed of my rights to privacy regarding my protected health information under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:
- Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers for my health care services.
- Conduct normal health care operations such as quality assessment and improvement activities.
I understand I must request in writing any changes in disclosures or restrictions of information other than stated in the above policy. I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
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Date*

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Enchantment Physical Therapy

Enchantment Physical Therapy Medical Screen Form

Cancellation and No Show Policy

Acknowledgement of Privacy Rights