If you are seeing us for physical therapy services, please fill out and/or sign the forms on this page prior to your first appointment! It shouldn’t take longer than five minutes.

PATIENT INFORMATION (1/5)

INFORMED CONSENT (2/5)

I understand that I am receiving physical therapy at Physio Strength Physical Therapy PLLC d/b/a PhysioStrength and/or Clinton Lee Physical Therapy LLC for an initial evaluation and/or treatment. This may consist of having any or all of the following: Reviewing my past medical history, a movement assessment, various objective tests & measures such as range of motion and strength, manual therapy, education regarding my plan of care and therapeutic exercise prescription. As with all forms of medical treatment, there are benefits and risks involved with physical therapy. As patient responses to a specific form of treatment can vary widely from patient to patient, it is not always possible to predict responses to a specific form of treatment. Therefore, Physio Strength Physical Therapy PLLC d/b/a PhysioStrength and/or Clinton Lee Physical Therapy LLC cannot guarantee any reaction or success to a given form of treatment. There is also a risk that your treatment may result in pain, injury, or may aggregative a previous condition. I may also discuss with my physical therapist the potential risks and benefits of a specific treatment and possible alternative treatments. I can stop evaluation and treatment at any time and am freely able to ask my physical therapist questions at any time during the evaluation/treatment session.   

PATIENT INFORMATION CONSENT FORM (3/5)

I understand that Physio Strength Physical Therapy PLLC d/b/a PhysioStrength and/or Clinton Lee Physical Therapy LLC may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the company. I also understand that the Company will consider requests for restrictions on a case by case basis, but does not have to agree to requests for restrictions. I hereby consent to the use and disclosure of my personal health information for purposes as noted in the Company’s Notice of Patient Privacy Practices. In doing so, I hereby release from any and all legal liability that may arise from the release of such information. I agree that a copy of this authorization may be used in place of the original.I understand that I retain the right to revoke this consent by notifying the Company in writing at any time except for that action which has already been taken. It shall be effective only long enough to answer the purpose of which it is given and no further confidential information will be released without the execution of an additional written authorization. I was provided access to, have read and understand the Notice of Patient Privacy Practices.

ASSIGNMENT OF BENEFITS (4/5)

I understand that my insurance company will be sent an itemized bill for each session in accordance to reasonable and customary charges. I agree to assign benefits directly to Physio Strength Physical Therapy PLLC d/b/a PhysioStrength and/or Clinton Lee Physical Therapy LLC for all therapy services rendered. I also agree to remit any monies sent to me from my insurance company for services rendered to Physio Strength Physical Therapy PLLC d/b/a PhysioStrength and/or Clinton Lee Physical Therapy LLC. I agree to pay for all services rendered UP to $200.00 (the out-of-pocket cost for a one hour initial evaluation or follow-up treatment) should my insurance company deny payment for services rendered and will be responsible for any deductible or co-insurance due as per the terms of my insurance plan. (Please enter full name below)

CANCELLATION POLICY (5/5)

In-person sessions at PhysioStrength are by made by appointment only; as such if a patient cancels without giving sufficient notice, it unfortunately prevents another patient from being seen. If you need to cancel your appointment, please do so at least 24 hours in advance through the cancellation link provided in your confirmation email OR by contacting your physical therapist directly.

If 24 hour notice is not provided or if the patient does not appear for their appointment as scheduled, unfortunately the patient will be charged for the full rate of the missed appointment, which is $250.00.

I have read, understood and agree to the above terms:

Please also fill out the insurance information form (last one, I promise)!

NOTICE OF PATIENT PRIVACY PRACTICES
(FYI)

According to the Health Insurance Portability and Accountability Act, known as HIPAA, physical, occupational and speech therapists in private practices must incorporate the federal privacy standards to protect patient’s medical records and other health information provided to health plans, doctors, hospitals and other health care providers.  Please note that Dr. Clinton Lee, PT, DPT/Clinton Lee Physical Therapy, LLC/PhysioStrength may use your personal health information for treatment, obtaining payment, during an audit, in emergencies, or when required by law. You will be asked for written authorization to use their personal medical information for any other reason than those listed above.  You have the right to review their personal health information at any time, to request that inaccurate information be corrected, or to request a list of instances when the information has been disclosed for reasons other than treatment, payment or other administrative purposes. You have the right to restrict how the information is used and disclosed for treatment, payment and administrative operations. The requests for restrictions will be considered on a case-by-case basis.  You have the right to address concerns and complaints about a potential violation of their health privacy to the US Department of Health and Human Services.

For further questions, you may contact the Compliance Officer:

Dr. Clinton Lee, PT, DPT
38 E 32nd Street
New York, NY 10016