Welcome To Thrive Proactive Health! We are grateful for you giving us the opportunity to become a partner is your health and wellness. We are dedicated to providing you with a great experience and we will work with you together to address your health concerns and keep you healthy!
INITIAL INTAKE CONSENT AND WAIVER
Name of referral
Thrive Proactive Health Friends and Family referral program offers both our current clients and their direct referrals a 20% discount off a service of their choice. We want to thank you from the bottom of our hearts for trusting us with your health care needs and for referring us your friends, co-workers, neighbors, and family members. Always remember there is absolutely no limit to how many referral rewards you can earn. Our gift to you includes 20% off your next visit for each and every customer that you refer who completes a qualifying service with us.
CONSENT FOR PARTICIPATION/WAIVER
I voluntarily consent to the services at THRIVE Proactive Health. I am aware that it is my right to accept or refuse any treatment/services offered to me. I understand it is my responsibility to communicate with the providers if I feel uncomfortable or wish to refuse to continue treatment/service at any time. I acknowledge and understand that no guarantee has been made to me as to the results that may be obtained from such treatment/services. It is this clinic’s sincere intent to educate me on every process and to provide me quality customer service and a successful outcome. It is my responsibility to ask questions and obtain a clearer understanding when needed.
ASSIGNMENT + BILLING INSURANCE BENEFITS
THRIVE Proactive Health is a private practice, holistic health clinic and advanced physical therapy provider. We do participate with certain insurance companies and use a third party billing company called Insyc to bill medical insurances and collect insurance payment for Physical Therapy Services provided to you. All of our clients are encouraged to contact their insurance company to determine their eligibility and to understand their plan’s coverage and limitations. As a courtesy to our patients, we will contact your insurance provider to help you understand your benefits and eligibility. It is important to understand all claims submitted are not a guarantee of payment. Coverage is based on eligibility and benefit status when the claim is filed. It is the patient/client/guarantor’s responsibility to pay any deductible, co-pay, co-insurance, or any other balance not paid for by their insurance company. I herby authorize release of medical information necessary to process my insurance claim and assign benefits directly to THRIVE Proactive Health.
*Must check one:
By checking this box, I verify I do NOT have Medicare Insurance.
By checking this box, I acknowledge that I do have Medicare Insurance coverage and am opting to receive services from a provider who is currently opted out of Medicare agreements. This means, I will not submit a claim or request a claim to be submitted to Medicare, and as a Beneficiary of Medicare I understand that NO reimbursement can or will be provided by Medicare for services provided at Thrive Proactive Health. I do accept full responsibility for payment in full at time of service in accordance to Thrive Proactive Health’s regular client price list.
HMO SPECIAL INSURANCE AGREEMENT
Certain insurance companies cater to typical physical therapy practices and fail to reimburse us for all of the advanced services we offer our clients. Just because your insurance company doesn’t pay for a service, doesn’t mean you shouldn’t receive it. You may supplement the cost to receive one of our essential or signature services that incorporates integrative techniques for patients to expect a faster recovery with better results if you wish. With the advanced services one can expect better results and less time commitment in coming into therapy. We value our time together and strive to help you achieve relief and an optimal outcome as fast as possible. This current policy applies to those who have Anthem Healthkeepers, Anthem HMO, Cigna, and United Health Care insurance policies. These policies will only pay for one 30 minute session with one of our providers per day. You are responsible for your copay, coinsurance, and deductible. In addition to your 30 minutes, you have options and may choose additional amenities at discounted rates. You may upgrade to add the Bio Q Pulse, Foot Detox, Dry needling or a Full Essential session for $30 (a $129 value) or a Physiomassage for $60 (a $159 value).
*Do you have Anthem HMO or Healthkeepers, Cigna, or United Health Care insurance policy?
check to acknowledge you read the above HMO special insurance agreement notes.
*Did you know Health Savings/Reimbursement accounts or Flexible Spending Accounts may be used for many of our services- including regular Massage Therapy, Foot Orthotics, and Physical Therapy co-pays, deductible and co-insurance responsibilities?
AUTHORIZATION FOR TREATMENT/RELEASE OF INFORMATION
I authorize provision of information concerning my care, condition, and treatment for quality assurance/risk management purposes. Protected Health information will never be released to any party not directly involved to the success of my outcome.
24 HOUR ADVANCE NOTICE FOR CANCELLATIONS/MISSED APPOINTMENTS
We request you to be courteous and give us a heads up if you are not going to make your appointment. We place great importance in accommodating all of our patients/clients and you providing a cancellation in advance allows us to manage our schedules and workflow better. In return, we can provide you, our customers, with the best service possible. If you fail to give us the requested notice and cancel in less than the 24 hour period more than 2 times, you will be required to have a card on file to prepay a scheduling fee or $50, which will go towards your service. If less than 24-hours is provided to reschedule or cancel, you will be subject to a $50 charge for the missed appointment. We truly desire to empower you in your health habits, and showing up to your appointments is important for you to reach your goals and achieve a good outcome. After you no-show one time, you will be required to have a card of file, which will be charged to pre-pay for your next appointment. If you have purchased a pre-paid package, there will be a deduction for the visit you missed. We appreciate the courtesy of a minimum 24-hour advance notice to reschedule or cancel your appointment.
It is up to you to inform your Provider about any health problems, allergies, as well as medications you are taking which may affect your care and well being while you are under treatment at THRIVE Proactive Health.
My voluntary participation along with this consent shall be on-going for the time period and participation in any service menu item, Physical + Massage Therapy, and coaching or Mental Performance training. In consideration of my participation in the programs/treatment at THRIVE Proactive Health, including use of equipment used in my treatments, I hereby waive for myself and on behalf of my heirs, claims of any nature arising from my participation in any programs/treatments, and do hereby release THRIVE Proactive Health, all of its employees and contractors, from any claims whatsoever arising from such participation. I agree to abide by all the rules for participants and instructions provided to me, and I understand the risks of such participation.
By signing this form, I verify the above info is complete to the best of knowledge.