Intake and Consent

At Format Physical Therapy, we are committed to protecting your privacy. This Intake and Consent form is how we collect, use, and safeguard your information when you visit our studio or use our services.

1. General Consent

Format PT is a hands-on manual therapy service that also utilizes Functional Orthopedics to teach our patients how to stay out of pain. Format PT  hands on treatments consist primarily of manual therapy techniques and methods that are published or otherwise publicly known. Format PT utilizes multiple approaches including but not limited to: (spinal manipulation, deep tissue massage, therapeutic exercise programs, blood flow restriction training, neuromuscular re-education, strain-counter strain therapy, myofascial release, IASTM, bone and soft tissue manipulation and mobilization and advanced trigger point therapy). Some of the hands-on treatment techniques require deep pressure, which may cause bruising and periods of increased soreness which may last from 1-72 hours. Symptoms may also change and move to other parts of the body. This is not unusual and is rarely a concern; however, please inform your therapist if you have any concerns or questions. I understand that Format PT is not liable for any injury sustained during and or post treatment. I waive my right to pursue any legal action against Format PT as our only intent to help each patient to the best of our ability. Format PT does not participate with any insurance provider and your consent to treat is mutually agreed upon during consultation. The number of treatments needed and recovery time can vary widely due to the age of injury, number of times injured, age of patient and many other  contributing factors. I have read and fully understand the above statements. I understand the nature of the treatments at Format PT and I authorize the fully trained staff to use treatment techniques as deemed necessary for my safe and effective recovery.

2. Treatment of Minors

I, as parent/guardian of a minor receiving treatment here under, do hereby
agree and understand that I have been advised to remain on the premises during
any such treatment, and waive any claim I may have resulting from failure to
do so.

3. Liability

I understand and agree that Format PT is not responsible for loss, theft, or damage
to personal valuables and belongings and hereby release Format PT from any
liability arising out of such loss, theft or damage to personal belongings.

4. Payment Agreement
Thank you for choosing Format PT as your physical therapy provider. Before we
begin services, please complete below indicating you have read, understand and
agree to the following payment policies. 

Payment is required at the time of
service, unless prior arrangement has been established and agreed upon. 

• Financially Responsibility: I agree to be financially responsible for all
charges regardless of any applicable insurance or benefit payments, third party interest, or the resolution of any legal action or lawsuits in which
you may be involved. 

• Forms of Payment: Format PT accepts cash, personal checks, square payments, on-line
payments (e.g., Chase quickpay, zelle, venmo) and credit cards.
Additional fees may apply with certain credit card transactions. 

• Out-of-Network Policy: Format PT is a fee-for-service. This means that
Format PT is not “in-network” with any private health plans or insurance
providers. Payment is due at the time of service. We can, upon request,
provide receipts with diagnosis and treatment codes which you may
submit to your private insurance company.

5. Privacy Rights
You have a right to privacy under the Health Insurance Portability and
Accountability Act (HIPAA) that includes restricting disclosure of your records
and claims to your health plan. By paying for your services at the time of
service, we assume you are exercising this right to privacy and we will not
disclose your medical records to any third party, including your health
insurance carrier or Medicare. If you want your records disclosed to any third
party in the future, you will need to obtain and sign our Disclosure to Release
Protected Health Information form before we will disclose your health
information.

6. Cancellation Policy
As a courtesy to Format PT staff and our clients, we require a 24-hour (or greater) notice for cancellations. This allows others on waiting lists to be seen. Only emergencies or illnesses are excusable. Clients who cancel appointments with less than a 24-hour notice will be charged a cancellation fee equivalent to the treatment session scheduled. This policy is not meant to be punitive, but it is reinforced to ensure that Format PT can continue to provide the premium level of 1-on-1 service that our clients deserve. To cancel or reschedule an appointment contact NYMT at 917-272-6375. 

If you consent please fill out the following form in its entirety.