PATIENT CONSENT, RIGHTS & FINANCIAL AGREEMENT
Patient Name: _____________________________________Date: ______________________
Date of Birth: ______________________

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1. CONSENT TO EVALUATION AND TREATMENT

I consent to evaluation and physical therapy treatment by the qualified physical therapists and other appropriately trained personnel at Transformative Pain Care and Physical Therapy, PLLC (“TPCPT”).

Treatment may include examination, therapeutic exercise, neuromuscular re-education, manual therapy, mobilization, massage, dry needling, physical agents, education, and other appropriate rehabilitation services.

I understand that physical therapy may involve temporary soreness, discomfort, fatigue, aggravation of symptoms, falls, or other risks. My therapist will explain proposed treatments, expected benefits, material risks, and reasonable alternatives when appropriate.

I may ask questions and may refuse or discontinue any treatment at any time. I understand that no specific outcome or result is guaranteed.

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2. MY RIGHTS

 

• I have the right to:

• Be treated with dignity, respect, and without unlawful discrimination.

• Receive appropriate and professional care within the provider's scope of practice.

• Be informed about my condition, treatment options, expected benefits, risks, and alternatives.

• Participate in developing and modifying my plan of care.

• Refuse or discontinue treatment.

• Request a second opinion or seek care from another provider.

• Receive information about applicable fees, policies, and insurance procedures.

• Have my health information handled in accordance with applicable law and TPCPT's Notice of Privacy Practices.

• Voice concerns or complaints without retaliation.

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3. MY RESPONSIBILITIES
I agree to:

• Provide accurate and complete medical and insurance information.

• Inform my therapist of changes in my condition, medications, or relevant medical history.

• Ask questions when I do not understand my treatment or instructions.

• Follow my treatment plan and safety instructions to the extent I am able.

• Treat TPCPT personnel and other patients respectfully.

• Keep my contact, insurance, and billing information current.

• Understand my insurance benefits and financial responsibility.

• Follow TPCPT's appointment and cancellation policies.

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4. FINANCIAL RESPONSIBILITY & INSURANCE
I understand that I am responsible for charges associated with my care, subject to applicable insurance contracts and law.

Insurance verification and billing is provided as a courtesy and is not a guarantee of payment. My insurance may deny or limit payment because of deductibles, copayments, coinsurance, authorization requirements, exclusions, benefit limitations, medical necessity, or other plan provisions.

I am responsible for applicable deductibles, copayments, coinsurance, and amounts not paid by my insurance, except where my responsibility is limited by law or contract.

I am responsible for providing current insurance information and for understanding my insurance benefits. Questions regarding coverage should be directed to my insurance carrier.

TPCPT may provide insurance-based, out-of-network, or direct-pay services depending on my circumstances and insurance plan. If I receive direct-pay services, payment is generally due at the time of service unless another arrangement has been approved in advance.

5. APPOINTMENT & CANCELLATION POLICY
TPCPT requests at least 24 hours' notice when an appointment must be canceled or rescheduled.  We have a large number of patients on our waiting list and giving us as much advanced notice as possible allows us the opportunity to offer those patients an earlier appointment, speeding up their recovery.  

There will be an $85 fee charged for: Cancellations with less than 24 hours' notice; A missed appointment/no-show; or Arrival more than 15 minutes late when the appointment cannot reasonably be completed.

This fee is not an insurance-covered medical service. It is the patient's responsibility.

Repeated late cancellations or no-shows may result in discharge from the practice.

To cancel or reschedule:
Phone/Text: 970-639-1948
Email: paindrkevin@transformativepain.com
Exceptions may be considered based on the circumstances.

6. COMMUNICATION & AUTHORIZED PERSONS
TPCPT may contact me using the information I provide for scheduling, appointment reminders, care coordination, and other permitted communications. By selecting text message or email, I acknowledge that SMS and email communications are subject to TPCPT's Website & Electronic Communications Terms of Use. 
Cell Phone: _______________________________________________
Email: ____________________________________________________
I authorize communication by:
☐ Text message
☐ Telephone/voicemail
☐ Email

I authorize TPCPT to communicate regarding my care, scheduling, and/or billing with:
Name: _______________________________________________
Phone: _______________________________________________
Relationship: __________________________________________

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Name: _______________________________________________
Phone: _______________________________________________
Relationship: __________________________________________
I understand that I may change or revoke these communication preferences or authorizations in writing, subject to applicable law.

7. GRIEVANCES & CONCERNS
TPCPT welcomes questions and concerns regarding care, services, billing, privacy, or personnel.

Concerns may be submitted verbally or in writing to:
Shiree Johnson, Director of Operations
Phone: 970-639-1948
Email: paindrkevin@transformativepain.com

TPCPT will make reasonable efforts to review and address concerns. Patients may voice grievances without discrimination, coercion, or retaliation.

8. ACKNOWLEDGMENT
By signing below, I acknowledge that:

• I have read and understand this agreement.

• I have had an opportunity to ask questions.

• I understand that I may refuse or discontinue treatment.

• I understand my financial responsibility.

• I understand that insurance verification is not a guarantee of payment.

• I understand TPCPT's appointment and cancellation policy and associated fees. 

• I acknowledge receipt of or access to TPCPT's Notice of Privacy Practices.

• The information I have provided is accurate to the best of my knowledge.

I consent to evaluation and treatment by Transformative Pain Care and Physical Therapy, PLLC.

Patient/Legal Representative Name: ______________________________________
Relationship to Patient (if applicable): ___________________________________
Signature: _____________________________________________________________
Date: ______________________
Witness/Staff Signature (if required): ____________________________________
Date: ______________________