I understand that my doctor has prescribed therapy for me and that physical therapy is an ongoing process which requires regular attendance to be optimally effective. I understand that if I am late for my appointment, I may be given the opportunity to reschedule my appointment or to accept an abbreviated treatment for that day. I understand that if I cancel or no show for 3 consecutive appointments, Rancho Physical Therapy has the right to discharge me from care for being non-compliant with my physician's orders.

I understand and agree that Rancho Physical Therapy requires 24 hour advance notice of cancellation. If I fail to give 24 hour notice of cancellation or fail to show up for an appointment, I may be subject to a $25 charge (which is not covered by insurance).

I have read and understand the appointment policy.

I understand and agree that insurance claim forms will be submitted to my insurance company as a matter of convenience only and that I am responsible for all charges regardless of my existing medical coverage. I understand that I am responsible for all supplies, such as braces or exercise equipment, which I am provided during treatment if they are not covered by my insurance plan. I understand that I will pay for supplies upon receipt and Rancho Physical Therapy will bill my insurance company and refund me any monies received by my insurance for the supplies.

I hereby give authorization for payment of insurance benefits to be made directly to Rancho Physical Therapy for services rendered. In the event that my insurance company forwards payment directly to me, instead of Rancho Physical Therapy, I will immediately deliver such payment to Rancho Physical Therapy.

I understand and agree that I am totally responsible and liable for payment of all charges assessed for professional services rendered and will pay any sum due upon demand. I understand and agree that if it becomes necessary to commence legal action for the collection of any outstanding charges on my account, I will be responsible for any costs and or court fees, in addition to the outstanding balance.