Release of Information: If I stated on the Patient Intake form to send treatment notes to someone then I am authorizing Kirk Integrative Physical Therapy (KIPT) to release information, verbal or written, contained in my medical record, and other information to the providers I noted on the Patient Intake form.

Permission for Messages: I authorize Kirk Integrative Physical Therapy to leave messages about my treatment, and about my appointment times, on my preferred phone voicemail or email (both of which are listed on the Patient Intake form.

Waiver of Insurance: As a patient of Kirk Integrative Physical Therapy (KIPT) I understand my insurance may not cover these services. I am instructing KIPT not to bill any insurance on my behalf.

• Medicare:  I have chosen, of my own free will, to enter into services at KIPT. I understand my choice and understand that this waives my ability to submit any claims independently.
• Non-Medicare:  If I choose to independently submit my physical therapy sessions to my insurance “out of network benefits,” I take full responsibility to verify my benefits and out of network deductible, and for all the administrative work it may require and do not hold KIPT liable if the claim is denied.

Cancellations, no-shows and refusal of service: I understand I will be charged full price for an appointment which I do not show up for, or cancel with less than 24 hours’ notice.

KIPT may refuse or suspend service to a patient under certain circumstances. Refusal or suspension of service is usually due to, but not limited to: nonpayment of account; repeated no-shows/cancelled appointments; non-notification of health changes; inappropriate behavior; and the therapist’s opinion that our services won’t benefit a patient.

HIPAA Patient Privacy Notice: My signature below indicates that I understand HIPAA Patient Privacy. I consent to your use and disclosure of protected health information about me for treatment, payment, health care operations, and/or as required by law and by HIPAA. A copy of HIPAA information will be provided if I request.

Consent for Treatment: I hereby authorize the professional staff at KIPT to evaluate and treat me or my dependent. During evaluation and treatment sessions, I authorize the licensed personnel at KIPT to use any and all techniques they have been trained to use, which they believe will benefit me. I have the right to refuse a specific technique or form of treatment if I so choose and will inform KIPT of this choice.

Payment:

• I understand that each visit is to be paid in full at the time of the visit.
• All payments may be made by cash, check, credit card, debit card or FSA/HSA card.
• A $5 convenience fee will be added to each payment made via credit card, debit card or FSA/HSA card.
• A returned check fee of $25 will be charged on all returned checks.

By signing this form electronically and clicking "Submit," you are agreeing to the terms stated herein.