Patient Consent Form

Your initials consent to the following: Fields marked with an asterisk (*) are required.

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers directly to Optimum Therapies of North Dakota, Inc.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

*As a service to patients, we provide via text, email or voicemail, of appointment reminder(s) and/or other types of notifications regarding your care and information regarding Optimum Therapies of North Dakota. By providing your contact information, you consent to receive such notifications.

*I have been informed of and given the right to review and secure a copy of Optimum Therapies HIPAA - Notice of Privacy Practices for Physical Therapy or Personal Training Disclosures. Click here to review HIPAA

*I agree to providing a 24 hour notice if I am unable to keep my appointment. I understand that a Late Cancel/No-Show occurrence, will incur a $50 charge.

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Authorization for Optimum Therapies of North Dakota to share/release my medical information with a 3rd party(spouse, parent, friend, etc.)

*Initial below for the service(s) you are receiving

(Physical Therapy)I authorize Optimum Therapies of North Dakota, Inc. to bill my insurance carrier and receive payment directly from the insurance carrier(s) or a third-party. I understand if payment by my insurance company is disputed or delayed, I am responsible for the payment of services rendered.

(Personal Training)I agree to pay for sessions at the time of service and understand that all packages are nonrefundable and non-transferrable. If I arrive late, I understand that I am still responsible for the full cost of the session booked. Private group classes are pre-booked and pre-paid. No refund for missed classes.

Please verify by signature that all information provided on the patient registration/consent form is accurate to the best of your knowledge.

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Signature:   

Date:   

*If patient is under 18 please use parent or guardian's signature.

What is your relationship to patient? (For patients under 18)