In agreeing to receive care provided by Pacific Neuro Therapy LLC and to use the facilities provided therefore by Pacific Neuro Therapy doing business as Apex Performance Wellness Rehab located at 10831 SW Cascade Ave. Suite 103, Tigard, Oregon, 97223, I agree as follows: 

I fully understand and acknowledge that (a) the activities in which I will engage as part of the treatment provided by Pacific Neuro Therapy, doing business as Apex Performance Wellness Rehab, and the physical therapy activities and equipment I may use as a part of that treatment have inherent risks, dangers, and hazards and such exists in my use of any equipment and my participation in these activities; (b) my participation in such activities and/or use of such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that, could cause serious disability; (c) these risks and dangers may be caused by the negligence of the representatives or employees of Apex Performance Wellness Rehab, the negligence of the participants, the negligence of others, accidents, breaches of contract, or other causes. By my participation in these activities and for use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or the conduct of the representatives or employees of Apex Performance Wellness Rehab, Pacific Neuro Therapy, or by any other person. 

I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify Apex Performance Wellness Rehab, and Pacific Neuro Therapy and their representatives, employees, and assigns from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of any equipment or participation in these activities. I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the representatives or employees of Apex Performance Wellness Rehab and Pacific Neuro Therapy. 

It’s my intention to exempt and relieve Pacific Neuro Therapy, and Apex Performance Wellness Rehab from liability for personal injury, property damage or wrongful death caused by negligence or any other cause.

All patients are expected to provide our office with current insurance information, verification of participation, identification, and a full understanding of your benefits. 

By agreeing to this form, you verify full understanding of your benefits and have provided our office with the most current information. 

By agreeing to this form, you acknowledge, agree to, and fully understand the Financial Obligation Policy.

• Your insurance company may not pay for the recommended plan of care. 
• Patient Responsibilities Include: deductible amounts, co-insurance amounts, co-payments, and all other procedures, treatments, and/or charges not covered by your insurance plan. 
• Payment is due upon notice of the amount due.
• For your convenience we accept cash, check, and all major credit cards at our office. 

Your health insurance is a contractual agreement between you and your health insurance company. You are FULLY financially responsible for any and all non-covered services. 

You may owe 100% of the billed amounts, if your insurance provider doesn’t cover charges. 

We stick to a strict schedule; appointment times are limited and we count on you showing up on time for every scheduled visit. 

As a courtesy to our therapists and other patients seeking care, we appreciate notice for open appointment times. Please be respectful of our therapist’s time and other patients who may fill those appointment slots.

We impose fees for: being late, cancelling an appointment without sufficient prior notice, and for not showing up to a scheduled appointment. 

• Late Fee: $40 - If you’re 15 minutes late for an appointment ($70 for 30 min 
• Cancellation Fee: $75 - Cancellations must be made by 8:00am the day of your appointment via email, voicemail, or text message. If your appointment is before 1pm, you must cancel the night before via email, voicemail or text message. 
• No Show Fee: $175 - If you fail to show up for an appointment, and provide no prior notice of cancelation.

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. 
• Obtain payments from third-party payers and conduct normal healthcare operations such as quality assessments and provider certifications. 
• I understand that as part of my healthcare, Apex originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. 

I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. 

By agreeing to this Consent Acknowledgement Form, you acknowledge, agree to and fully understand the Health Insurance Portability & Accountability Act. Also, by agreeing to this form, you are agreeing that the information you’ve provided is yours and it is your current health information.

I give permission to Pacific Neuro Therapy & Apex Performance Wellness Rehab and/or parties designated by them, to photograph & video me and use such photograph(s)/video(s) in all forms of media, for any and all promotional purposes including advertising, display, audiovisual, exhibition or editorial use. 

I further consent to the use of my name in connection with the photograph(s)/video(s) if needed by Pacific Neuro Therapy & Apex Performance Wellness Rehab. I understand and agree that I will not receive any payment for my time or expenses or any royalty for the publication of the photograph(s)/video(s) or the use of my name and I hereby release Pacific Neuro Therapy and Apex Performance Wellness Rehab from any such claims. 

I certify that I have read and fully understand this consent and release, and that all questions pertaining to this consent have been answered to my satisfaction.