HeartMath & Sleep Coaching Consent to Treat and Financial Policies

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

I hereby agree to be a participant in a ____________________________ program designed by Karen Tom and Peak Physical Therapy, LLC. * *

Heartmath

Sleep Coaching

Both

Financial Policy: I understand that payment for service is due at the time of service. For HeartMath and Sleep Coaching, the fee is $125 for each session. I agree that Peak Physical Therapy, LLC may discuss my treatment with my physician for the purpose of my care only. It is my right to understand the treatment which I am participating in and I can refuse participation at any time. By initialing and signing this form, I consent to HeartMath and/or Sleep Coaching. INITIAL: *

I acknowledge that I have been highly recommended to have a physical exam by a licensed physician prior to starting a HeartMath and/or Sleep Coaching program. I hereby affirm that I am in good physical health and do not suffer any disability that would prevent or limit my participation in this HeartMath and/or Sleep Coaching program or cause or aggravate an existing medical/injury condition. INITIAL: *

In consideration of my participation in this HeartMath and/or Sleep Coaching program for myself, my heirs and assigns, hereby release Karen Tom and Peak Physical Therapy, LLC from any claims, recommendations, and causes of action arising from my participation in the HeartMath and/or Sleep Coaching program. INITIAL: *

I hereby release Karen Tom and Peak Physical Therapy, LLC from any liability now or in the future including, but not limited to, illness, injury, or death however caused occurring during, or after my participation. I acknowledge that I have been highly recommended to stop/cease participation if I experience health problems including, but not limited to, digestive problems, abnormal blood pressure, shortness of breath, dizziness, or chest pain and see a licensed physician. INITIAL: *

This HeartMath and/or Sleep Coaching program is educational and informational only and assumes no responsibility for the correct or incorrect use of the information. Any information provided and any recommendations made should not be used to, nor are they intended to, diagnose, treat, cure or prevent any existing or future disease and/or medical condition. No attempt should be made to use any information provided as a form of treatment for any specific condition or disease without the approval and guidance of a licensed health physician. INITIAL: *

I have read and understand the above agreement; I have been able to ask questions regarding any concerns I might have; I have had those questions answered to my satisfaction; and I am freely signing this agreement. PRINT NAME: *

Privacy: I understand that PEAK will strive to maintain my privacy to the highest standards, but I also understand that all electronic transmissions are subject to hacking and malfeasance. I do agree that PEAK may use or disclose my personal health information for the purposes of carrying out my treatment, evaluating the quality of services provided to me, and for administrative operations related to treatment or payment. To help assure privacy, I agree that I will provide PEAK with an e-mail address that only I have access to, that I will use a secure password for that email address, and that I will use multifactor authentication to protect the security of that email address and password. PEAK may utilize the e-mail address I have provided to PEAK for all communications with PEAK including conveying my personal medical information. Release of medical records: I have reviewed the HIPAA Privacy Rules shown to me by PEAK and I authorize the PEAK to release my medical records to my physician/primary care provider and my insurance company. I agree that PEAK may discuss my treatment with my physician for the purpose of my care only. I also agree that PEAK may utilize my medical records in responding to requests for reimbursement. By typing my name below, I am providing my electronic signature acknowledging the above policies (If the patient is less than 18 years of age, the parent or legal guardian must type both their child’s name as well as their name below. By signing below, parents are signing on behalf of their child but are also agreeing that they are personally responsible for the treatment provided to their child under this Agreement.) *

Date *

YYYY

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of PEAK Physical Therapy, LLC. Report Abuse

Forms