- I consent to hands-on treatment and evaluation necessary for the care of the above patient.
- I authorize the release of medical records and information for treatment, billing, or claims, and permit The New Jersey Centers of Physical Therapy (NJCPT) to appeal insurance denials on my behalf.
- I understand NJCPT is Out-of-Network with most insurers, have been informed of In-Network options, and have chosen to receive care here.
- I have reviewed my financial obligations with a Client Care Specialist and accept my shared responsibility.
- I will provide NJCPT with all checks and Explanation of Benefits received from my insurer for services provided within one week, as these payments are the legal property of NJCPT.
- I agree to notify NJCPT in advance if I must cancel an appointment. Missed or uncancelled appointments will incur a $20 charge per occurrence.
Release of Liability
I understand that treatment may involve exercises, manual techniques, and the use of equipment, which carry inherent risks such as temporary soreness, muscle strain, dizziness, falls, or other accidental injury. I voluntarily choose to receive treatment at The New Jersey Centers of Physical Therapy and understand I may ask questions at any time about the nature, purpose, and potential risks of my care.
I agree to fully disclose all relevant medical conditions and health factors that may affect my treatment or increase my risk of injury. I release and hold harmless the practice, its owners, employees, and contractors from claims relating to the inherent risks of therapy, except in cases of gross negligence or willful misconduct.
If the patient is under 18, I confirm that I am the parent or legal guardian and consent to treatment under these terms.
In the event of a medical emergency, I authorize staff to obtain emergency care on my behalf, with associated costs being my responsibility.
HIPAA Privacy Practice Notice
Effective Date: April 14, 2003 | Revised Date: September 23, 2013
The New Jersey Centers of Physical Therapy is required by law to maintain the privacy of, and provide individuals with, a copy of our legal duties and privacy practices with respect to protected health information.
We will not give out any of your personal information without your consent, except as allowed or required by law.
The Notice of Privacy Practices describes how medical information about you may be used and disclosed, and how you can get access to this information. You have the right to request the Notice of Privacy Practices prior to signing this consent.
Questions? Please direct any questions to:
Director of Clinical Services
New Jersey Doctors of Physical Therapy
69 Newark Pompton Turnpike, Riverdale, NJ 07457
973-248-8111
