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Questionnaire

Please fill out the following form

Do you authorize Dynamic Gains Physical Therapy to bill your insurance? If payment for physical therapy is recieved by anyone other than Dynamic Gains Physical Therapy, do you forfeit payment to Dynamic Gains Physical Therapy for services rendered?
Physical Therapy, virtual sessions, and exercise all involve risk, as you are without physical assistance and support. Do you waive liability of Dynamic Gains Physical Therapy and therapists for any injury or medical event which may occur and do you participate at your own risk?

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Medical History

Please describe your medical history below, including any prior conditions, surgeries, and medications you may be taking

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Consent to treat and bill insurance

       AUTHORIZATION:

  1. I hereby authorize Dynamic Gains Physical Therapy healthcare professionals and students to provide such medical care and to administer such treatment, necessary to the named patient or me each time myself or the named patient present to an ambulatory care service. Such procedures and treatments may include, Physical Therapy and Fitness. 

  2. To the extent possible I have been informed of risks and complications that may occur and alternatives that may be available. I acknowledge that no guarantees or assurances have been made to me concerning the results intended from my treatment.  I am participating at my own risk and do not hold the therapist or Dynamic Gains Physical Therapy liable for any injury, cardiovascular or medical event that may result from exercising or treatment.

       GUARANTEE OF ACCOUNT

  1. Any payment rendered by the insurance carrier for Physical Therapy services will be forfeited to Dynamic Gains Physical Therapy.    

  2. It is our commitment to make your financial responsibility to Dynamic Gains Physical Therapy transparent.  Deductible and co-insurance responsibility will be discussed and agreed upon prior to the appointment.  It is the patient's responsibility to provide the agreed amount to Dynamic Gains Physical Therapy for services.   

4.  RELEASE OF INFORMATION

  1.  I permit Dynamic Gains Physical Therapy to disclose all or part of the below patient’s medical records to any person, corporation, or agency when required for the collection of benefits or payment of Dynamic Gains Physical Therapy charges.

5.   HIPAA – NOTICE OF PRIVACY ACKNOWLEDGMENT

  1. Dynamic Gains Physical Therapy has made their Notice of Privacy Practices available to you. Your name, signature, time and date on this cover sheet indicate that you acknowledge the availability of the Dynamic Gains Physical Therapy and were given the option to receive a copy of your possession. If you have any questions regarding the information set forth, please do not hesitate to contact Dynamic Gains Physical Therapy. 

Do you have a physical therapy script?
Do you authorize Dynamic Gains PT to treat, bill insurance, release information when approrpiate, gaurentee payment and account?

Thanks for submitting!

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