Kayser Physical Therapy & Fitness Amanda Kayser, LLC
CONSENT, DISCLOSURE, AND PRIVACY
I hereby give consent to AMANDA KAYSER, LLC to provide the desired services, be it physical therapy, wellness, exercise or massage, as requested by myself, or my family member(s).
I, or my family, have provided full disclosure of any and all relevant past medical history that may impact, influence or contraindicate the prescribed service provided by AMANDA KAYSER,LLC.
I understand that AMANDA KAYSER, LLC is fully licensed and its providing therapists are highly trained and skilled. They (AMANDA KAYSER, LLC) will ensure that the service they provide is safe, appropriate, and indicated for my condition.
While AMANDA KAYSER, LLC fully intends to give service that offers no harm, I understand that there is ALWAYS THE POTENTIAL FOR AN UNFORESEEN ACCIDENT TO OCCUR. Should this be the case, I recognize that AMANDA KAYSER, LLC has taken every necessary precaution to protect me, and therefore, I DO NOT HOLD AMANDA KAYSER, LLC liable for any unforeseen injury.
I understand that AMANDA KAYSER, LLC is a private pay company, and not contracted with any insurance companies, including Medicare. Amanda Kayser, LLC will not submit insurance claims for me. However, I understand that it is my right to submit invoices provided to me upon request to my insurance company. I also understand that it is my responsibility to know my insurance policy and their requirements for reimbursement. I understand that reimbursement from my insurance is not guaranteed.
AMANDA KAYSER, LLC ensures that information about me and my condition, or reason for receiving services, will remain private and be fully disclosed ONLY upon my approval.