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Consent to Treatment
I hereby authorize the professional staff at Hallett Physical Therapy to examine and treat me with physical therapy for the symptoms I have been referred here for or referred myself for.
I understand that Hallett Physical Therapy complies with HIPAA and will protect my Protected Health Information (PHI). I understand my information will be used as allowable by law in the treatment, billing and collection pertaining to my care until my case is closed an full payment is received. I also authorize the release of any information pertinent to my case to my insurance company, adjuster, attorney, or medical provider for the purpose of securing payment. This authorization remains in effect until 90 days from the date of the last bill collected.
**For MEDICARE patients only**
I hereby instruct my insurance company/companies (Medicare) to pay by check made out to and mailed directly to Hallett Physical Therapy for professional or medical expenses allowable and otherwise payable to me under my current insurance policy. This is a direct assignment of my rights and benefits under this policy. This payment will not exceed my indebtedness to the above-mentioned assignee and I have agreed to pay, in a current manner, any balance of said professional fees for non-covered services and/or fees over and above the insurance payment or as required by my insurance policy. 
An important part of your treatment may include the use of biofeedback. This will be fully explained prior to receiving such treatment. A special sensor/electrodes are required for treatment, the cost of which may not be covered by your insurance company. By signing below you agree to the one time charge of $45 that is payable at the first session

Thank you!

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