Physical Therapy Consent for Care and Financial Responsibility Agreement

Patient First Name *

Part 1: Consent for Treatment

A: Consent *

I, the undersigned, consent to receive physical therapy care from Beyond Care Physical Therapy & Wellness PC (“Provider”) and their start, including assistants and other healthcare personnel. This may include Evaluation and physical examination; Diagnostic and functional testing; Treatment interventions and therapeutic procedures deemed necessary. I understand that physical therapy is not an exact science, and no results can be guaranteed.

Part 2: California-Specific Disclosures for Physical Therapy

A. Direct Access Notice *

California law allows patients to receive physical therapy services without a physician’s referral for up to 45 calendar days or 12 visits, whichever comes first. After this limit, continued treatment requires a written signature from a licensed physician or podiatrist approving the plan of care. This notice has been provided to me both orally and in writing, in at least 14-point type, and I acknowledge it by signing below.

B. Scope of Practice Notice *

I understand that my physical therapist will provide a physical therapy diagnosis, which is distinct from a medical diagnosis by a physician. I understand that physical therapists cannot prescribe medications, order imaging, or treat conditions outside the scope of physical therapy practice.

C. Informed Consent Requirements *

My physical therapist has explained, in clear terms, and I understand that the reason for treatment and proposed plan has been explained; The nature, frequency, and expected duration of interventions were described; The benefits and likely outcomes, both with and without therapy, were discussed; Potential risks, side effects, and alternatives were disclosed; I have the right to accept or decline any treatment and may withdraw consent at any time.

Part 3: Assignment of Insurance Benefits

Insurance *

I authorize my insurance company to send payment for covered services directly to the Provider. I understand I am responsible for all charges not covered by insurance, including copayments, deductibles, co-insurance, and non-covered services.

Part 4: Financial Responsibility Agreement

A. Billing and Payment *

Payment for copayments, deductibles, and cost-sharing amounts is due at the time of service unless prior arrangements are made. I am responsible for all balances not paid by my insurance plan.

B. Out-of-Network Services (if applicable) *

I am responsible for confirming whether the Provider is in-network with my plan. Non-emergency services: If the Provider is out-of-network, the No Surprises Act protects me from some unexpected bills. I may waive those protections by signing a separate consent, which may result in higher costs. Emergency services: By law, I am only responsible for in-network cost-sharing, regardless of Provider’s network status.

C. No Insurance / Self-Pay Patients *

If I do not have active health insurance, I agree to be responsible for the full cost of services. Payment is due at the time of service unless other arrangements have been made in advance.

D. Collections *

If my account is not paid in a timely manner, the Provider may refer it to a collection agency. Additional fees may apply, as permitted by California law.

Part 5: Late Cancellation & No-Show Policy

A: Appointments & Scheduling *

We value your time and ours. Please provide at least 24 hours’ notice if you need to cancel or reschedule your appointment. Late cancellation (less than 24 hours): $ 25.00 fee may be charged. No-show (missed appointment without notice): $ 25.00 fee may be charged. These fees are not covered by insurance and are the patient’s responsibility. Repeated late cancellations or no-shows may affect your ability to schedule future appointments.

Part 6: Patient Acknowledgment and Signature

By signing below, I acknowledge that I have read, understood, and agreed to the terms of this consent, financial responsibility agreement, and California-specific disclosures for physical therapy.

Patient/Authorized Representative Signature: *

Clear

Relationship to Patient (if applicable):

Part 7: Provider Acknowledgment

The Provider’s representative has reviewed this form with the patient or their authorized representative, who understands the terms of this agreement.

Provider Representative Signature:

Clear

(Provider)Printed Name:

(Provider) Date of signature

Important Note for Providers:

This form is designed for California physical therapy practices. It includes required disclosures under California law and federal regulations (No Surprises Act). Providers should have all consent and financial forms reviewed by legal counsel to ensure compliance with current state and federal laws, including Medi-Cal policies when applicable.