Pain Character (Check all that apply):

Please check any conditions you have been diagnosed with:

By signing below, I authorize Advanced Rehabilitation Clinics Inc to bill my insurance carrier(s) directly and assign all benefits payable under my insurance policy to Advanced Rehabilitation Clinics Inc for services rendered. I also authorize the release of any medical information necessary to process my claim. I understand that I am ultimately responsible for all charges not covered by my insurance.

Voluntary Consent

I voluntarily consent to physical therapy evaluation and treatment by the licensed physical therapists and supervised clinical staff of Advanced Rehabilitation Clinics Inc. I understand treatment may include, but is not limited to: manual therapy, therapeutic exercise, modalities (ultrasound, electrical stimulation, heat/cold), dry needling, and functional activities.

Risks and Benefits

I understand physical therapy, like all healthcare treatments, involves some risk. Potential risks include temporary soreness, muscle aches, bruising, and in rare cases, injury. The therapist will discuss expected outcomes and any specific risks with me prior to initiating treatment.

Right to Refuse or Withdraw

I have the right to refuse or discontinue any treatment at any time without affecting my right to future care. I may ask questions about my condition and plan of care at any time.

Photography / Video

consent to photographs or video recordings for the sole purpose of documenting my progress and facilitating my treatment. Images will not be used for any other purpose without additional consent.

How we use your information

Advanced Rehabilitation Clinics Inc may use and disclose your protected health information (PHI) for treatment, payment, and healthcare operations. For example, we share information with your referring physician, your insurance company for billing purposes, and within our practice for coordination of care.

Your Rights

You have the right to request restrictions on how we use your PHI, receive confidential communications, inspect and copy your health records, request an amendment to your records, receive a list of disclosures, file a complaint with us or with the U.S. Department of Health and Human Services.

Authorizations

Uses or disclosures beyond treatment, payment, and operations require your written authorization, which you may revoke at any time. Examples include marketing, research, or sale of PHI.

Our Obligations

Advanced Rehabilitation Clinics Inc is required by law to maintain the privacy of your PHI, provide you with this notice, and notify you following a breach of unsecured PHI. A full copy of our Notice of Privacy Practices is available upon request.

By signing below, I acknowledge I have read this Consent to Evaluation and Treatment and Notice of Privacy Practices (HIPAA I consent to the evaluation and treatment described above and acknowledge receipt of the Notice of Privacy Practices (HIPAA

Insurance Verification

We will make every effort to verify your insurance benefits prior to your first appointment. However, benefit verification is not a guarantee of payment. You are ultimately responsible for all charges not paid by your insurer, including deductibles, copays, coinsurance, and non- covered services.

Payment at Time of Service

Copays, coinsurance, and known patient balances are due at the time of service. We accept cash, check, Visa, Mastercard, Discover, and American Express.

Deductibles & Coinsurance

If your plan has a deductible, you will be billed for your portion after insurance processes the claim. Payment of your balance is expected within 30 days of the statement date.

Non-covered Services & Balances

If your insurance denies a claim or determines services are not covered, you will be responsible for the full charge. We will notify you of any anticipated non-covered services in advance whenever possible.

Cancellation Policy

We require at least 24 hours advance notice to cancel or reschedule an appointment. Late cancellations (less than 24 hours) and no-shows may be charged a $50 fee. This fee is not billable to insurance and is the patient's responsibility.

Workers' Compensation & Auto

If your treatment is related to a workers compensation claim or motor vehicle accident, you must provide valid claim information at your first visit. If your claim is denied or closed, you will be responsible for all charges.

Past Due Accounts

Accounts past due by 90 days may be referred to a collection agency. You will be responsible for all collection costs, including reasonable attorney fees. A $50 returned check fee will be applied to all returned checks.

Assignment of Benefits

By signing this form, you authorize Advanced Rehabilitation Clinics Inc to bill your insurance directly and assign your benefits to our practice.

I have read and understand Advanced Rehabilitation Clinics Inc's financial policy. I agree to pay all charges for services rendered, including deductibles, copays, coinsurance, and any non- covered amounts. I authorize Advanced Rehabilitation Clinics Inc to release any information required for insurance.