New Patient Form

Please contact our office at least 24 hours in advance if any appointment cannot be kept. We recommend that you reschedule your appointment in order to remain on course to meet your rehabilitation goals.

If you are late to your appointment, circumstances may require that your appointment be shortened or rescheduled to another date and time.
You may be discharged from therapy if multiple (greater than two) appointments are missed without advanced notice (i.e. no-show). Depending on your insurance you may then need a new therapy prescription prior to returning to therapy. If your therapy is being covered by worker’s compensation then we are required to report any missed appointments.

Failure to cancel or reschedule 24 hours in advance of your appointment will result in a $50.00 Fee Due Prior to Next Appointment.
I understand the above policies of Performance Evolution Physical Therapy, and agree to abide by these policies kept. We recommend that you reschedule your appointment in order to remain on course to meet your rehabilitation goals.

If you are late to your appointment, circumstances may require that your appointment be shortened or rescheduled to another date and time.
You may be discharged from therapy if multiple (greater than two) appointments are missed without advanced notice (i.e. no-show). Depending on your insurance you may then need a new therapy prescription prior to returning to therapy. If your therapy is being covered by worker’s compensation then we are required to report any missed appointments.

Failure to cancel or reschedule 24 hours in advance of your appointment will result in a $50.00 Fee Due Prior to Next Appointment. I understand the above policies of Performance Evolution Physical Therapy, and agree to abide by these policies

Medical Consent:
The undersigned hereby authorizes providers to render to patient physical therapy and wellness services (collectively referred to as “services”) that the Provider (physical therapist) determines may be necessary or advisable. Patient agrees to cooperate with
all reasonable requests by Provider in connection with Provider’s rendition of services. The undersigned acknowledges that no guarantees have been made as to the results of assessment of treatment. Services rendered at Performance Evolution, LLC are a combination of current best practices supported by literature and expert opinion.

Medical Records Release:
The Patient or the guarantor of the account hereby authorizes Performance Evolution, LLC to release Patient’s medical record (including any information furnished to Provider or obtained by Provider in connection with Patient’s treatment) to any referring physician, insurance company, healthcare facility, or governmental agency (including the Social Security Administration or any of its intermediaries or carriers)
requesting such information. Authorization is also given to the release of records to insurance carriers for the purpose of payment of claims including worker’s compensation claims to both carrier and employer.

Medical Insurance Benefits:
The undersigned, hereby assigns to Provider all private medical insurance benefits (primary, secondary, and medi-gap providers) or other benefits to which Patient may be entitled for any services rendered by Provider. The undersigned hereby authorizes and directs Provider to apply and file for all such benefits on behalf of Patient.

Medicare and Medicaid Authorization:
I certify that the information given by me in applying for payment under Titles XVII and IXIX of the Social Security Act is correct and I request payment of authorized benefits to the made on my behalf. I authorize the Provider to release to the Medicare Bureau, Health Care Financing Administration or its intermediaries or its carriers, any information about me needed for Medicare claim, including medical information for the purpose of processing a claim for Medicare benefits. I also authorize the release of medical and related information about my treatment to the utilization and quality control peer review organization responsible for reviewing the medical care furnished to me. I further state under both titles that I do not have any other insurance that is to be filed primary over my Medicare and/or Medicaid.

HIPPA Disclosure:
I understand Performance Evolution, LLC will maintain my privacy as it is included in my patient rights. My information may be used for administrative, billing, and clinical
purposes.

Acknowledgement of Receipt of Privacy Practice Notice:
By signing this form you acknowledge receipt of the Notice of Privacy Practices. I have read and understand the above policies