Terms and Conditions
Authorization for Outpatient Treatment
The undersigned has been informed of the SpineZone Medical Fitness, Inc. (“SpineZone Medical Fitness”) Program treatment considered necessary and that the treatment will be guided by physical therapists, physical therapy assistants, physician assistants, and spine rehabilitation specialists or other assistants employed by SpineZone Medical Fitness(collectively, “Providers”) including through video calls and virtual evaluations (collectively, “Video Calls”). Authorization is granted for such treatment as prescribed by the undersigned’s physician, or as directed by the physical therapists under California “Consumer Direct Access”, which allows patients to receive direct physical therapist services and treatment without first obtaining a physician diagnosis or referral subject to certain requirements, as described below.
The undersigned acknowledges that as part of their treatment they will be engaging in physical exercises and using exercise equipment and as with all such physical activity there is an inherent risk of injury or complication to their existing condition. The undersigned voluntarily participates in these physical activities and knowingly and freely assumes all risks of injury, loss or damage on account of these activities. The undersigned understands that while treatment will be provided in accordance with recognized medical standards and clinical practice guidelines, results are not guaranteed and that they have the right to discuss the purposes and risks associated with all recommended treatment procedures and activities with their Provider. The undersigned further understands that their Provider’s advice, recommendations, and/or decisions may be based on factors not within the Provider’s control, including incomplete or inaccurate information provided by the undersigned. The undersigned understands that their Provider relies on information provided by them, and that the undersigned must provide information about their medical history, condition(s), and current or previous medical care that is complete and accurate to the best of their ability. The undersigned further understands that in the event of an emergency, the undersigned should not contact their Provider or SpineZone Medical Fitness, but should immediately call “911” and request emergency care assistance.
Telehealth Services (if applicable)
The undersigned understands that if he/she receives treatment through Video Calls, the Provider interacting with the undersigned may not have the benefit of information that would be obtained through in-person treatment and evaluation. Accordingly, the undersigned’s Provider may not be fully aware of facts or other information that may affect the Provider’s opinion regarding a potential treatment recommendation for the undersigned. The undersigned understands that their Provider may determine in his/her sole discretion that the undersigned’s condition is not suitable for treatment using Video Calls, and that the undersigned may need to seek in-patient treatment or treatment from an alternative source.
The undersigned further understands that there are potential risks to the telehealth technology used for Video Calls, including interruptions, unauthorized access, loss of information and delays in evaluation and treatment arising from technical difficulties and the potential inability of their Provider to provide appropriate treatment via telehealth consultation. The undersigned also understands that the delivery of health care services through telehealth is an evolving field and that the use of telehealth in their treatment may include uses of technology not specifically described in this authorization form.
The undersigned is also aware that in addition to their Provider, other SpineZone Medical Fitness staff members may be present during the Video Calls. The undersigned understands that they will be informed of the presence of any SpineZone Medical Fitness staff members during their Video Call, and will have the right to consent to their presence as part of the Video Call. The authorized staff will at all times maintain the privacy and confidentiality of the information obtained pursuant to the Video Call. The undersigned understands that the same confidentiality and privacy protections that apply to in-person treatment and other health care services also apply to the Video Calls.
Notice of Privacy Practices
The undersigned acknowledges receiving a copy to review of SpineZone Medical Fitness’ Notice of Privacy Practices. Additional copies are available upon request.
Release of Billing Information and Assignment of Insurance Benefits
The undersigned requests that payment of authorized Insurance benefits be made on the patients’ behalf to SpineZone Medical Fitness for any service furnished to the patient by the Provider. The undersigned authorizes any holder of medical information about him/her to be released to insurance companies, as well as any information necessary to pay the claim.
The undersigned agrees, whether he/she signs as an agent or as a patient, that in consideration of the services to be rendered to the patient, he/she hereby individually obligates him/herself to pay all monies due in accordance with the regular rates and terms of SpineZone Medical Fitness. In addition, the undersigned understands that he/she will be financially responsible for all charges incurred.
The undersigned understands that it is their responsibility to determine whether SpineZone Medical Fitness’ services are covered by their insurance company. Co-payments, co-insurance, payments for non-covered services and/or deductibles are due at the time of the appointment. Monies not collected prior to the appointment will be the patient's responsibility.
All patient accounts are due and payable upon receipt of a billing statement. If it is necessary to employ a professional collection agency and/or attorney to enforce this Agreement to collect a judgment based on this Agreement, the patient or person responsible for payment of fees related to the account that is the subject of this Agreement promises to pay all applicable interest, court costs and attorney fees. SpineZone Medical Fitness reserves the right to deny non-emergency services if the undersigned’s account is delinquent.
The undersigned hereby agrees to provide 24 hours advance notice (by 12:00 p.m. one day prior to your scheduled appointment) for all cancelled appointments. To cancel a Monday appointment, please call our office by 12:00 p.m. on Friday. Should 24 hours advanced notice (by 12:00 p.m.) not be provided, he/she understand that they may be charged a missed appointment fee of $25.
The undersigned agrees that he/she must be eligible with their health insurance plan at the time of the appointment. The undersigned understands and agrees that SpineZone Medical Fitness will not take responsibility for the refusal of an insurance company to pay for testing or treatment due to lack of insurance benefits. If he/she is unable to provide insurance coverage at the time of the appointment, he/she will assume full financial responsibility for all charges incurred. In addition, should insurance eligibility status terminate retroactively, he/she will be financially responsible for any services provided.
The undersigned acknowledges that your physician may have a financial interest in the services provided at SpineZone Medical Fitness. As the patient you have the right to choose another provider of spine rehabilitation or physical therapy.
Kamshad Raiszadeh, MD holds an ownership interest in SpineZone Medical Fitness.
If you choose another option for treatment, please contact your insurance company for assistance.
Direct Physical Therapy Treatment Services
You are receiving direct physical therapy treatment services from an individual who is a physical therapist licensed by the Physical Therapy Board of California.
Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time a physical therapist may continue providing you with physical therapy treatment services only after receiving, from a person holding a physician and surgeon’s certificate issued by the Medical Board of California or by the Osteopathic Medical Board of California, or from a person holding a certificate to practice podiatric medicine from the California Board of Podiatric Medicine and acting within his or her scope of practice, a dated signature on the physical therapist’s plan of care indicating approval of the physical therapist’s plan of care and that an in-person patient examination and evaluation was conducted by the physician and surgeon or podiatrist.
Patient Health Plan Change
Please promptly inform us if your health plan changes to ensure you are not accruing additional expenses.
I acknowledge that I have been informed regarding the SpineZone Medical Fitness Program treatment, including the possible benefits, risks, and limitations, and I have received a copy of this signed authorization form. I acknowledge that I have been given the opportunity to ask questions regarding the SpineZone Medical Fitness Program treatment, and my questions have been answered to my satisfaction.
I understand that I may withdraw this authorization at any time, except to the extent that SpineZone Medical Fitness has already acted based on my consent, by providing SpineZone Medical Fitness with written notice at firstname.lastname@example.org. Unless revoked earlier, this authorization will remain valid for the duration of one (1) year, and will expire one (1) year from the date of my signature below.