Thank you for choosing Patricia Fasciotti Wellness, LLC. This is an agreement between Patricia Fasciotti Wellness, LLC and you regarding our policies.
CONSENT TO TREATMENT
I authorize Patricia Fasciotti Wellness, LLC to provide physical therapy evaluations and treatment.
Highly specialized skilled treatment may include manual therapy techniques, including forms of deep tissue massage, myofascial release, and joint mobilization, in addition to therapeutic exercise programs, neuromuscular re-education, and other treatment techniques.
The number of treatments needed and recovery time can vary widely due to the age of injury, number of times injured, age of patient and many other contributing factors.No guarantees have been made to me about the outcome of therapy.
I have read and fully understand the above statements. I understand the nature of the treatments from Patricia Fasciotti Wellness, LLC, and I authorize the fully trained staff to use treatment techniques as deemed necessary for my safe and effective recovery
CHARGE FOR SERVICES
You agree to be financially responsible for all charges regardless of any applicable insurance or benefit payments, third-party interest, or the resolution of any legal action or lawsuits in which you may be involved. Patricia Fasciotti Wellness, LLC is a fee-for-service provider. This means that we are not “in-network” with any private health plans. Payment is due at the time of service and we will not bill your insurance company.
Payment will take place at time of service through cash, check, credit card, or online payment through Paypal.
A $50 fee will be charged for each returned check. You will be asked to pay for your next session in cash to cover the amount of the returned check and the $50 returned check fee.
Patricia Fasciotti Wellness, LLC does not bill insurance.
If you plan to submit bills to your insurance company, you should:
- Check with your insurance company before your first visit to find out what services they will pay for.
- You may need a referral from your doctor. You may need a pre-authorization from your insurance company.
- Referrals and pre-authorizations do not guarantee that insurance will pay for services.
All therapy sessions, diagnoses, and family history information will be kept confidential. You have a right to privacy under the Health Insurance Portability and Accountability Act (HIPAA) that includes restricting disclosure of your records and claims to your health plan, including Medicare, if you pay privately for your services at the time of service. By paying for your services at the time of service, we assume you are exercising this right to privacy and we will not disclose your medical records to any third party, including your health insurance carrier or Medicare.
CANCELLATION AND ATTENDANCE POLICY
As a courtesy to our therapists and other patients trying to get scheduled, we require a 24-hour (or greater) notice for cancellation to avoid full charge for missed services.
Cancellations that occur on the day of therapy due to client medical illness or other unforeseen emergencies will not incur a cancellation fee.
If cancellations are made with less than 24 hours notice, you will be charged the full rate for the cancelled session.
Termination of therapy services is voluntary at any time.
I have read, understand, and agree to abide by the aforementioned policies.