Patient Agreement and Authorization

Thank you for choosing E.W. Myofascial Therapies Clinic (“EWMT”). To facilitate your treatment at EWMT, please carefully read and sign this agreement and authorization regarding the following terms:

1. EWMT is a fee for service business. All payment is due at the time of service and is non-re- fundable. INSURANCE IS NOT ACCEPTED. Your insurance company will NOT be billed, nor will EWMT provide payment receipts for services rendered for purposes of insurance billing or reimbursement. Cash, personal checks, Venmo, and credit cards are accepted for payment. All credit cards payments are subject to a 3% processing fee. All other forms of payment are not subject to these fees.
2. Evaluations for all new patients and new conditions are $240 for eighty (80) minutes. The rate for all treatment sessions (during normal business hours and that are not part of a pre- paid package) is $160 for fifty (50) minutes. Supplies and supplemental items, such as tape, TENS unit rental, and other supplies are considered additional costs and are charged in addition to the standard rate. Professional records review of diagnostic exams or tests for interpretation of professional opinions without treatment will be charged a separate fee of $35. Pre-paid package discount plans, that may be offered by EWMT, are non-refundable and all such pre-paid treatment must be used within six months of payment. If you have questions regarding charges or fees, please ask for clarification prior to your first treatment. Additional information about fees and costs may be found on EWMT’s business website
3. EWMT is NOT a Medicare provider. Medicare will NOT pay for services at EWMT as EWMT is NOT a participating provider with Medicare or any other insurance company. You will NOT be able to submit reimbursement for services as they do not meet the rules set by Medicare regulations. This pertains to all patients at EWMT. Therefore, any receipts you may request from EWMT will not include diagnosis codes and other information that insurance claims usually possess or require.
4. As a courtesy to other patients and therapist work schedules, a 24-hour or greater cancellation notice is required. Only emergencies and illness are excusable. You will be billed for the entire appointment fee upon violation of this policy, which must be paid prior to your next appointment. Failure to show for a scheduled appointment will also result in being billed for the entire appointment fee.
5. EWMT cannot and does not guarantee confidentiality when using cell phones, texting, and email to communicate. The most secure form of communication is face-to-face. If you choose to use cell phones, texting, or email to contact or communicate with EWMT or its therapist(s), you hereby give consent for EWMT and its therapist(s) to use that media with you, and you assume any risks to confidentiality breaches while using said media.
6. You may leave therapy at any time and agree to discuss the termination of therapy with your EWMT therapist. Likewise, EWMT may, consistent with its ethical and legal requirements and obligations, terminate your therapy. If therapy is terminated by you or EWMT, you will be responsible to fully pay for any services rendered prior to termination.
7. Your EWMT therapist is not a medical doctor, and it is not the intent of EWMT to replace traditional medical care. All EWMT therapies, treatments, and education programs are de- signed to enhance your total wellness, and they should be used in conjunction with your traditional medical care. If you have any concerns about new therapies or making medical- related decisions, you should consult your medical professional.
8. You are voluntarily agreeing to the treatment and therapy offered by EWMT and you under- stand and agree that there are risks involved with such treatment. You will be provided with the EWMT Informed Consent agreement prior to beginning your treatment, and you must fully read and agree to it prior to your treatment at EWMT.
9. You will receive, read, and agree to the Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations prior to treatment at EWMT.
10. By agreeing to the terms of this agreement and authorization for treatment at EWMT, to the fullest extent allowed by law, you agree to release from liability, discharge, acquit, forgive, hold harmless and waive your right to sue EWMT, and its employees, therapists, contractors, owners, agents, representatives, lawyers and all agents of EWMT, from any and all claims, alleged claims, actions, suits and/or demands related to or resulting from actual or alleged physical injury, illness (including death) or economic loss in any way related to your treatment at EWMT. This release shall be binding upon and inure to the benefit of the par- ties, their successors, assigns and personal representatives.
11. You agree to immediately address any grievance you may have directly with your therapist. If the matter cannot be settled, then a jointly agreed-upon outside consultation with a neutral party such as a mediator will be sought. If the dispute cannot be settled after this informal process, the dispute may be settled only through arbitration. BY SIGNING THIS AGREEMENT, YOU ARE AGREEING TO HAVE ANY ISSUE, GRIEVANCE OR CLAIM DECIDED BY ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL.
12. In case any provision in this agreement shall be invalid, illegal or unenforceable, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired thereby and such provision shall be ineffective only to the extent of such invalidity, illegality or unenforceability.

Acceptance and Authorization

I have read and fully understand the above terms. By signing agreement and authorization, it is my informed decision to receive therapeutic services and treatment at EWMT.

I ALSO UNDERSTAND AND AGREE THAT MY INSURANCE WILL NOT REIMBURSE FOR SERVICES RENDERED BY EWMT.