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Please fill out and sign the following form

Acknowledgment of Polices, Service Agreement, and Consent

With my signature below I acknowledge that I have read, been made aware of and fully understand to my satisfaction, the Snow Sport and Spine Policy consisting of office policies related to: insurance, finances, worker's compensation and auto accident liability, consent to treat, and patient privacy. I have had an opportunity to ask questions and receive answers. If I am a Medicare beneficiary, a separate private contract for care will be presented to me for a signature in the office.

  • I have been made aware of the privacy policies at Snow Sport and Spine and understand that a copy of the Notice of Privacy Practices is available to me upon request.

  • I understand that Snow Sport and Spine does not bill insurance for my services, and I agree to pay my bill in full at the end of each visit.

  • I understand the benefits and risks involved in physical therapy. I agree to fully cooperate and participate in the proposed physical therapy interventions in the established plan of care of my therapist. I understand I have the right to revoke this consent, in writing, at any time, except to the extent that my physical therapist and Snow Sport and Spine has taken action in reliance on this consent.

Please check the box next to each statement you agree with.

I have been made aware of the inherent risks of communicating via email. I authorize email exchange between Snow Sport and Spine and myself as follows (check all that apply).

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