The HIPAA privacy rules give patients the right to request restrictions on the use and disclosure of their protected health information.

I, the undersigned, give permission to La Verne Physical Therapy, its employees and associates, to share any and all aspects of my medical records with the following people:

I acknowledge that the Notice of Privacy Practices and the Notice for Federal Civil Rights are posted at the location where I am receiving treatment, and that I have read and understand the notice. I further acknowledge that I have the right to request a copy of the notice and that one will be provided to me.

I authorize La Verne Physical Therapy to release to appropriate agencies any information acquired in the course of my or the named patient's examination and treatment that is necessary to secure payment for services provided.

As the patient or the patient's financial representative, you understand and agree to the following:

1. All patients must pay the estimated cost of their office visit at the time of the visit if the insurance policy deductible has not been met. Copays and co-insurances will also be estimated and must be paid at the time of the service. If these are not paid at the time of service, a $10.00 fee will be assessed to the account for each visit.
2. A $35.00 fee will be assessed on all returned checks.
3. You are responsible for your account balance after 60 days, whether or not it is paid by your insurance.
4. We verify patient insurance benefits as a courtesy to you. However, you are responsible for knowing your insurance coverage and benefits, and it is your responsibility to make La Verne Physical Therapy aware of any changes to your insurance plan or coverage.
5. You authorize care and treatment by La Verne Physical Therapy and release all information to insurance and third-party carriers, and direct them to remit payments directly to La Verne Physical Therapy.
6. Accounts past 90 days will be charged interest at a rate of 2% monthly (20% annually). A late fee of up to $40.00 per month may be charged on past due accounts.
7. If the account is assigned to an agency for collections, it is agreed that the financial representative will pay all attorney fees, with or without suit, court costs, and a collection fee of up to 40% of the balance, which will be added to the outstanding balance of the account. The terms of this agreement also apply to any unpaid amounts owed prior to this agreement, and for services that will be rendered in the future.
8. A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit reporting agency.
9. Self pay patients will receive services at a discounted rate, but must be paid in full at the time of service.
10. A notice of 24 hours for canceled appointments is appreciated. A $40.00 charge will be assessed to the account if there are more than 2 missed appointments without notification (no-show or same day cancel). You will then be charged a $40.00 fee for each no-show or same day cancel thereafter.

Thank you for your understanding as we all adjust to our nation's healthcare plans.

(revised August 2025)

I, the undersigned [print name] ("Participant"), hereby acknowledge that I have voluntarily elected to participate in La Verne Physical Therapy ("Activity"), to be held in and around the La Verne Physical Therapy Clinic.

In consideration for being permitted to participate in the La Verne Physical Therapy, I hereby acknowledge and agree to the following:

ELECTIVE PARTICIPATION: I acknowledge that my participation is elective and voluntary and that my participation is not required by the La Verne Physical Therapy Clinic.

RULES AND REQUIREMENTS: I agree to conduct myself in accordance with La Verne Physical Therapy Clinic policies and procedures. I further agree to abide by all the rules and requirements of the Activity. I acknowledge that the La Verne Physical Therapy Clinic has the right to terminate my participation in the Activity if it is determined that my conduct is detrimental to the best interests of the group, my conduct violates any rule of the Activity, or for any other reason in La Verne Physical Therapy Clinic's.

INFORMED CONSENT & ASSUMPTION OF RISK: I have been informed of and I understand the various aspects of the Activity. I understand that there are risks involved in participation in the Activity which include, but are not limited to: bodily injury, pain, disease, strains, fractures, partial and/or total paralysis, death or other ailments that could cause serious disability, injuries due to condition of equipment, facility conditions, wildlife, negligent first-aid operations and there may be other risks not known to me or not reasonably foreseeable to me at this time. I understand that as a participant in the Activity I could sustain personal injuries, illness, and/or property damage as a consequence of not only La Verne Physical Therapy Clinic's actions or inactions, but also the actions, negligence or fault of others, and there may be other risks not known to me or not reasonably foreseeable at this time. I further understand and agree that any injury, illness, disability and/or property damage that I may sustain by any means is my sole responsibility, except for those occurrences due to La Verne Physical Therapy Clinic's negligence or intentional acts. I KNOWINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE ACTS OF LA VERNE PHYSICAL THERAPY, DIRECTORS, EMPLOYEES, VOLUNTEERS, AND ANY STUDENTS ("Releasees") UNLESS THEY ARISE FROM INTENTIONAL OR NEGLIGENT ACTS OF THE RELEASEES, AND ASSUME FULL RESPONSIBILITY FOR MY PARTICIPATION IN THE PROGRAM. I further understand that my therapist may use an electronic scribe or other recording tool during my visit for clinical documentation purposes only. Any such recording is used solely to prepare my medical record, is protected under the same privacy practices that apply to the rest of my chart, and is not used for any other purpose.

RELEASE AND WAIVER OF LIABILITY & INDEMNIFICATION: I, on behalf of myself, my personal representative, heirs, executors, administrators, agents, and assigns agree to HOLD HARMLESS, DEFEND, INDEMNIFY, RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE Releasees for any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys' fees) arising from any injury, illness, disability and/or property damage that I may suffer as a result of my participation in the Activity, REGARDLESS OF WHETHER THE INJURY, ILLNESS, DISABILITY AND/OR DAMAGE IS CAUSED BY THE RELEASEES, UNLESS THE INJURY, ILLNESS, DISABILITY AND/OR DAMAGE IS CAUSED BY THE RELEASEES' NEGLIGENCE OR INTENTIONAL ACTS, AND REGARDLESS OF WHETHER THE INJURY, ILLNESS, DISABILITY AND/OR DAMAGE OCCURS WHILE IN, ON, UPON, OR IN TRANSIT TO OR FROM THE PREMISES WHERE THE ACTIVITY, OR ANY ADJUNCT TO THE ACTIVITY, OCCURS OR IS BEING CONDUCTED. I further agree that the Releasees are not in any way responsible for any injury, illness, disability and/or damage that I sustain as a result of my own negligent acts.

MEDICAL CONSENT: I understand and agree that Releasees may not have medical personnel available at the location of the Activity. In the event of any medical emergency, I authorize and consent to any diagnosis or treatment, and hospital care the La Verne Physical Therapy Clinic personnel deem necessary for my safety and protection. I understand and agree that Releasees assume no responsibility for any injury or damage which might arise in connection with such authorized emergency medical treatment.

I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASEES. I UNDERSTAND I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS AGREEMENT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. BY MY SIGNATURE I REPRESENT THAT I AM AT LEAST EIGHTEEN YEARS OF AGE.

(rev 8/2025)