Consent For Care & Treatment: I the undersigned, do hereby agree and give my consent for SPARK Physical Therapy, LLC via Duane Scotti, PT, DPT, PhD, OCS to furnish medical care and treatment that is considered necessary and proper in diagnosing or treating his/her physical condition.
Insurance Reimbursement: SPARK Physical Therapy, LLC and all treatment provided by Duane Scotti, PT, DPT, PhD, OCS are out of network for all insurance providers. Your signature below indicates you are financially responsible for all charges incurred and understand your insurance carrier will not be billed for services provided.
Payment: Payment is due at time of treatment unless otherwise agreed upon.
By signing below, I certify that I have read the above policies, understand and will comply with them. I agree that SPARK Physical Therapy, LLC retains the right to charge me for any fees incurred as described above and that I will be solely responsible for all charges incurred.
Phone Communication: We may need to contact you. Do we have your permission to leave a confidential message at the phone numbers you provided us? Your signature below indicates you are have agreed for us to send you this message at your preferred method of contact.
Email/ Text Communication Statement (regarding security): I, the undersigned, understand and accept the risk involved with email and text communication of my personal health information if I choose to participate. I allow SPARK Physical Therapy, LLC to initiate and respond to my email and/or text messages regarding matters relating to my medical care. I am aware of the risk that any transmission of email and text messages can be intercepted and read by a third party. I am also aware that all email and text communications may become part of my medical record. I understand that SPARK Physical Therapy, LLC does not share email addresses or phone numbers with any third party.
Consent for Use and Disclosure of Health Information: I have had full opportunity to read the SPARK Physical Therapy, LLC Notice of Privacy Practices. I understand that by signing this consent, I am giving my consent to SPARK Physical Therapy, LLC to use and disclose my protected health information to carry out treatment and health care operations. I understand the terms of this notice may change with time and SPARK Physical Therapy, LLC will always have copies available for distribution.
SIGNATURE for CONSENT:
By clicking on “I AGREE” on the final questions located on the SPARK Physical Therapy intake form, located at https://forms.gle/Qh3gzHSzBNoaNffp9 , I confirm that I have read all of the above information and I consent to physical therapy evaluation and treatment.
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