KNOW YOUR INSURANCE BENEFITS
This is an agreement between KOH Physical Therapy, Inc. (KOHPT) and the Patient/Responsible Party signed on this form. By executing this agreement, you are responsible for all medical bills and other charges that result from services rendered by KOH PT Deductible and co-payments are due at time services are rendered. If not paid by following visit, a fee will be assessed. No EXCEPTIONS.

It is our pleasure to assist you in maximizing your insurance benefit by completing your claim forms. As a courtesy, in addition to filing your claim, we will initially ask for your estimated co-payment. This is only an estimate based upon the information available to us. Once your carrier has paid the claim, any remaining balance is your responsibility. Remember benefits quoted are not a guarantee of payment.

ASSIGNMENT OF BENEFITS: I hereby instruct and assign my insurance carrier to KOHPT for the professional/medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I hereby authorize said assignee to release all information necessary to secure the payment, via fax transmittal or hard copy. Medical records will be accessible to all therapists of KOHPT. I have read this policy and I am satisfied that I understand the entire contents and significance of the terms.

CONSENT TO TREATMENT: I hereby consent to the therapeutic procedures outlined and to be performed by KOHPT and their associates.I agree to be evaluated and treated for functional loss due to related nerve, muscle, and skeletal dysfunctions and/or pain. I understand that therapeutic procedures can include, but are not limited to: joint and soft tissue mobilization, home exercise programs, functional training including: posture and body mechanics, modalities, such as: heat, ice, electrical stimulation, and ultrasound, and special procedures such as: taping, neuromuscular electrical stimulation, and bladder training. I understand that I will be explained the purpose of the therapeutic procedures prior to receiving treatment and that I may refuse any therapeutic procedure or treatment at any time. I understand that I may consult with other therapists and/or physicians at any time regarding my condition.

TELEHEALTH SERVICES
Patient verbally consented to a telehealth encounter after patient was informed of visit limitations with the use of technology and technical failures that may interrupt or stop the video connection during the session. Patient was informed of the right to withhold or withdraw their consent to the use of telehealth in the course of their care at any time.

NOTICE OF PRIVACY PRACTICES: This notice describes how medical information about you may be used and disclosed and how you can get access to this information. I hereby acknowledge that I can get a copy of this practice’s Notice of Privacy Practices. I have read this policy and I am satisfied that I understand the entire contents and significance of the terms.

TELEPHONE CONSUMER PROTECTION ACT
By providing us with a telephone number for a landline, cellular or other wireless device, I agree that, in order for us or our service providers to service your account(s) (including contacting you about appointments, obtaining potential financial assistance for your account(s) (or to collect any amounts you may owe, we, our agents, representatives, or other service providers may contact you at the telephone numbers(s) provided. I expressly consent that methods of contact may include using telephone calls, text messaging, pre-recorded and artificial voice messages and/or the use of an automatic dialing device, as applicable. This consent applies to all services and billing associated with the patient, parent/legal guardian.

CONSENT FOR ELECTRONIC MAIL (EMAIL) USE
I consent that KOHPT Lab can provide their services and communicate with me via mobile phone, messages, e-mail and any kind of online communications, provided that these communications comply with privacy regulations.

APPOINTMENT REMINDERS, RESCHEDULES AND CANCELLATIONS
I understand that KOHPT Lab can reach me any time to remind me of my appointments or let me know in case of any change about my appointments. And I also understand that KOHPT can employ and use a third-party automated system to reach out me for the purpose of "confirm", "reschedule" or "cancel"

FINANCIAL POLICY: KOHPT is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. All insurance companies are not the same in what they consider to be usual and customary fees. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. We recommend that you read over your policy and contact your carrier if you have any questions regarding your coverage. I have read this policy and I am satisfied that I understand the entire contents and significance of the terms.

DENIAL, DELAY OR NEGLIGENCE: KOHPT is not responsible if your insurance carrier denies, delays, or is negligent with its estimated co-payments. When delayed, we will extend the reimbursement period up to thirty (30) days from date of service. This time period will not be extended to patients who provide us with the incorrect insurance information, fail to keep the information current or fail to fill out the necessary forms which their insurance carrier may request in a timely manner. If your insurance carrier postpones payment for more than 90 days, we ask that you make the remaining payment while we work together to get the insurance carrier to pay the obligated amount. Services are due and payable at the time they are rendered unless other arrangements are made in advance. A 10% finance charge will apply on accounts 60 days past due. If account becomes past due, we will take necessary steps in contacting you to collect this debt. If these attempts do not generate a response from you, your account could be subject to the following fees: Finance Charges (currently 10%), In House Collection Fees, Collection Agency fees and any Attorney fees. If you have a balance on your account, we will send you a monthly statement. Unless other arrangements are approved by us in writing, the balance on your statement is due and payable on or before the due date specified on the statement and is past due if not paid on or before that date. We do charge interest (10%) on all past due accounts; interest will begin accruing once the account becomes 60 days past due. I have read this policy and I am satisfied that I understand the entire contents and significance of the terms.

ARBITRATION PROVISION: Any dispute, claim or controversy arising out of or relating to this Agreement or the breach, termination, enforcement, interpretation or validity thereof, including the determination of the scope or applicability of this agreement to arbitrate, shall be determined by arbitration in Orange County, California, before one arbitrator. The arbitration shall be administered by JAMS pursuant to its Comprehensive Arbitration Rules and Procedures. Judgment on the Award may be entered in any court having jurisdiction. This clause shall not preclude parties from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction. Allocation of Fees and Costs: The arbitrator may, in the Award, allocate all or part of the costs of the arbitration, including the fees of the arbitrator and the reasonable attorneys’ fees of the prevailing party.

BY SIGNING THIS AGREEMENT YOU ARE AGREEING TO HAVE ANY ISSUE RELATING TO THIS AGREEMENT DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL.

If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. I understand and acknowledge with the arbitration provision.