YOU WILL RECEIVE THE CHOSEN REMINDER ONE DAY BEFORE YOUR APPOINTMENT (OR ON FRIDAYS FOR MONDAY APPTS.) HOWEVER, PLEASE NOTE THAT THE APPOINTMENT YOU MAKE IS YOUR RESPONSIBILITY TO KEEP, REGARDLESS IF YOU RECEIVE YOUR REMINDER OR NOT. This is a courtesy service that usually works, under some circumstances reminders have not been delivered (ie. blocks on cellular services, same phone number for family members).
Please check below to acknowledge that you have access or can obtain a copy of our Notice of Privacy Practices from the front desk at any time. It addresses how your health information may be used, disclosed and accessed. HIPAA
We have reserved your appointment time just for you. You are responsible to show up for your appointment or cancel at least 24 hours in advance. If you do not, we charge a $45.00 no show/cancellation fee for the 1st and 2nd missed appointment, and $95 for the 3rd and 4th missed appointment. This fee must be paid before another appointment is scheduled. Any additional no-shows and you will be discharged from the clinic..
If my insurance is being billed, I authorize Tensegrity Physical Therapy to release to my insurance company any information which may be necessary to process my insurance claim. I also assign the benefits which are payable for my services to Tensegrity Physical Therapy.
If you have a deductible that has not been met, your insurance will not pay us for your visits until your annual deductible is satisfied. Our policy is to collect an amount to offset your final balance until your deductible is satisfied. The deposit amount for your first visit is dependent on insurance, and for follow ups the amount is $100. After your insurance processes your visit and sends us the explanation of benefit, we will apply the amount you have paid and bill you for the balance. There will be another bill due. If there is a credit on your account after the insurance processes those visits, there will be a refund issued.
You may have a co-payment or coinsurance amount that you are responsible for each visit that we collect at the time of treatment. A final bill may be sent after we receive the explanation of payment from your insurance.
Since your insurance coverage is a contract between you and the insurance company, it is ultimately your responsibility to understand your benefits. If there is a discrepancy of benefits quoted, the plan terms prevail since Tensegrity P.T. is only a third party to you and your insurer.
Unless prior arrangements are made, all balances are due within 30 days of being billed. Failure to pay or communicate with the office will result in your account being turned over to collections. In Oregon, the spouse’s credit will be affected, as well as yours, and additional fees may incur.
Most insurance policies have an annual limit to the number of physical therapy visits you can have. You are responsible for knowing and tracking the number of visits for physical therapy allowed by your insurance plan. PT visits at other facilities are included in that number and treatment for multiple injuries or surgeries also count. If the annual number is exceeded, you are responsible to pay out of pocket. We will do our best to assist you when asked about the count, but you are ultimately responsible.
I acknowledge and consent to the performance of physical rehabilitation including various modes of manual therapy from Tensegrity’s practitioners, which may include spinal manipulation and/or mobilizations if deemed applicable on me. Prior to the treatment, there will be an explanation of how it will benefit and what is to be expected. I understand and am informed that there are some risks to treatments, in which the provider will follow evidence based practice to determine course of the procedure.
During the physical therapy evaluation for the symptoms that you have reported, an assessment of your lower back, hips, and pelvic girdle
will be performed by the physcial therapist in order to identify any potential muscoskeletal deficits or dysfunction. Depending on symptoms,
this evaluation might include an examination of your pelvic floor muscles for strength, resting tone/tension, and coordination.
Your examination may include an internal assessment of the pelvic floor muscles, which could be completed vaginally (females) or rectally (males & females).
Your physical therapist will discuss this option and receive your consent before initiating this exam. If you are uncomfortable with this option,
you can absolutely say no; your physical therapist can assess and treat the pelvic floor muscles externally if needed. The findings of this
examination will be discussed with you, and together you and your physical therapist will develop a treatment plan. The internal assessment of the
pelvic floor may results in soreness or discomfort temporarily. If this does occur, please discuss with your physical therapist.
Our physical therapists know that many people may be apprehensive because of the private nature of the condition and the intimacy of the
examination. We encourage you to ask as many questions as you need to increase your comfort and understanding of all aspects of your experience
with us. Please talk with your physical therapist about any concerns or hesitation you may have.
By signing this form, you agree and understand that treatment as indicated above may be necessary for effective treatment of your problem, and
you agree that we have your permission to treat as discussed. You are always free to change your mind at any time during your course of treatment,
and you are encouraged to notify your physical therapist of any changes of your preferences.
You do have the option to have a second person in the room for the pelvic floor muscle evaluation and treatment. The second person could be a friend,
family member, or clinic staff member. Please indicate your preference below then enter your initials.
I have read and understand the Informed Consent for Pelvic Floor Muscle Evaluation, and I consent to the evaluation and treatment, unless otherwise noted below.
Draw a mark or circle your problem on the body chart below.