Legal Forms

For new patients: If you want to save time, please fill out all forms electronically prior to your initial visit/evaluation. If you do not have the forms filled out prior to your first visit, know that this time will be used during your appointment.

Returning Patients: For returning patients, please make sure to discuss with your therapist any new changes to your medical history prior to your appointment.

Treatment Sessions: A session typically lasts for 45-60 minutes. For your evaluation and each follow-up visit, please wear or bring athletic shoes and clothes that are appropriate for exercise and that allow us to treat at and around the affected area. (such as shorts, yoga pants or sweat pants and t-shirt or tank top).

Liability: I understand and agree that Liberty Physical Therapy, LLC is not responsible for loss or damage to personal valuables.

Waiver and Release: I hereby release, discharge, and acquit Liberty Physical Therapy, LLC, its agents, representatives, affiliates, and employees, from any and all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive or allow emergency and/or medical services including, but not limited to, ambulance service, emergency medical technician or paramedic services and physician or urgent care services.

Informed consent for treatment: The term “informed consent” means that the potential risks, benefits, and alternatives of physical therapy treatment have been explained to me.  The therapist provides a wide range of services, and I understand that I will receive information at the initial visit concerning the treatment and options available for my condition. 

Liberty Physical Therapy, LLC is hands-on Physical Therapy. Thorough, highly specialized treatment consists primarily of manual therapy techniques and treatment forms that are published or otherwise publicly known. Forms of deep tissue massage, therapeutic exercise programs, therapeutic activities, neuromuscular re-education, dry needling, myofascial release, bone, and soft tissue manipulation, as well as other treatment modalities, may be used. Some of the hands-on treatment techniques require deep pressure, which may cause bruising and periods of increased soreness that could last from 6-72 hours. Your therapist will review your plan of care and discuss these treatment options with you in order for you to provide specific consent. Symptoms may also change and move to other parts of the body. This is not unusual, and it is rarely a concern. However, please ask if you have any concerns or questions. The number of treatments needed and recovery time can vary due to the duration of injury, number of times injured, age of the patient, and many other contributing factors.

Potential risks: I understand I may experience an increase in my current level of pain or discomfort or an aggravation of my existing injury.  This discomfort is usually temporary. If it does not subside in 24 hours, I agree to contact my physical therapist.

Potential benefits may include an improvement in my symptoms and an increase in my ability to perform my daily activities.  I may experience increased strength, awareness, flexibility, and endurance in my movements.  I may experience decreased pain and discomfort.  I should gain greater knowledge about managing my condition and the resources available to me.

Alternatives:  If I do not wish to participate in the therapy program, I will discuss my medical, surgical, or pharmacological alternatives with my physician or primary care provider.

I hereby give authorization and consent to be treated by Liberty Physical Therapy, LLC for the injury/illness for which I have consulted. In doing so, I voluntarily consent to the rendering of such care within the physical therapy scope of practice by the state of Minnesota, in the judgment of my therapist, as deemed necessary.

Medical Records/Notice of Privacy: I understand and agree that Liberty Physical Therapy, LLC will maintain my privacy to the highest standards and may ONLY 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 involved in my medical care.

I agree that Liberty Physical Therapy, LLC may obtain information from others who have provided medical care to me and/or are responsible for the payment of all or part of my bills when this information is needed in order to treat, bill, and/or receive payment. 

I authorize the release of my medical records when appropriate and upon verbal agreement to my physicians/primary care provider, other medical providers, insurance companies, or Alpha 1 Personal Training/Snap Fitness (Lakeville, MN/Rosemount, MN) to ensure continued quality of care. A formal Release of Information form can be filled out and signed upon request.

Notification of HIPAA: I acknowledge that I have received or been offered a copy of Liberty Physical Therapy, LLC’s Notice of Privacy Practice, which describes how my PHI is used and shared. I understand that Liberty Physical Therapy, LLC has the right to change this notice at any time. I may obtain a current copy by contacting Liberty Physical Therapy, LLC. My signature below acknowledges that I have been offered a copy or provided with a copy of the Notice of Privacy Practice.

I have read “Notice of Privacy Practices” as mandated by HIPAA.

Payment/Insurance Reimbursement: I understand that Liberty Physical Therapy, LLC is a fee-for-service clinic and will not bill my insurance company. I agree to pay for my evaluation and treatments in full at the time of service, by cash, check, or credit card/charge card [Health Savings Accounts (HSAs), and Flexible Spending Accounts (FSAs)] unless other mutually agreed upon arrangements have been made.  I understand Minnesota is a direct access state and a physician’s referral is not required to make an appointment. If your treatment goes beyond the 90-day allotted direct access treatment timeframe, you will be responsible for obtaining a Physical Therapy Order from a qualified provider. I understand it is my responsibility to call my insurance company ahead of time and obtain any information that is necessary, as well as get an estimate of my benefits.  I understand my therapist will provide me with a receipt, upon request, and that is my responsibility to submit to my insurance company. If further documentation is requested, these will be provided. I understand that Liberty Physical Therapy, LLC does not guarantee I will receive any reimbursement from my insurance company, even if I submit a receipt and/or superbill provided Liberty Physical Therapy, LLC. I understand and agree that Liberty Physical Therapy, LLC does not accept auto accident liens.

Medicare/VA/Medicaid/Tricare/Government Sponsored Insurance Policy.  If you are a Medicare beneficiary (including a Medicare supplemental insurance plan, Medicare Advantage Plan, or Medicare Replacement Plan) or have a government-sponsored health insurance plan such as the Veteran’s Affairs (VA), Medicaid, Tricare, etc.., you understand that our licensed physical therapists are not enrolled as Medicare providers or government-sponsored health insurance providers.  Medicare, the VA, and other government-sponsored health insurance plans have onerous technical and administrative requirements that must be met for services to be considered medically necessary covered benefits.  We believe those requirements take unnecessary time away from the services we provide and many of the post-rehab services or fitness/wellness we offer are not covered by Medicare, the VA, and other government-sponsored health insurance plans.  Since we are not enrolled providers, we cannot submit claims to Medicare or other government-sponsored health insurance providers and Medicare/VA/Government Sponsored health insurance will not pay for our services even though the same services might be paid by Medicare/VA/Government Sponsored health insurance if you obtained them from a Medicare/VA/Government Sponsored health insurance enrolled provider. Therefore, by choosing our services, you are exercising your right to privacy and electing, of your own free will, not to use your Medicare/VA/Government Sponsored health insurance benefits. As such, you are agreeing to pay cash at the time of service for all services you elect to receive from us with no expectation that Medicare/VA/Government Sponsored health insurance providers will reimburse you.  You understand that we will not submit claims to Medicare/VA/Government Sponsored health insurance providers on your behalf or provide you with a statement or billing codes that you can submit to Medicare/VA/Government Sponsored health insurance providers yourself. You are also agreeing that you will not submit claims to your secondary insurance (if applicable) as they will oftentimes forward the claim to Medicare (primary payor).

If you want Medicare/VA/Government Sponsored health insurance providers to pay for services that might be considered covered benefits, you should seek those services from a Medicare/VA/Government Sponsored health insurance enrolled provider. If you decide at any point after you start services with us that you want Medicare to pay for the services it covers, we will be happy to recommend a Medicare/VA/Government Sponsored health insurance enrolled provider and terminate your services with us.  You agree that you, your caregivers, family members, authorized representatives or power of attorney will not, under any circumstance, submit our claims, invoices, receipts or statements to Medicare/VA/Government Sponsored health insurance for reimbursement or to obtain a denial for a Medicare supplemental insurance plan.  

Your signature below indicates you are financially responsible for all charges incurred and that outstanding balances over 90 days can be processed by a collection agency.

Newsletter and Contact: If you supplied an email address, you will be signed up for our email newsletter. This will include updates, news, classes, deals, presentations and the like. If you do not wish to receive these, please indicate that to your therapist or just unsubscribe on your own.

Media Release: I grant permission to Liberty Physical Therapy, LLC, hereinafter known as the “Media” to use my image (photographs and/or video and written reviews) for use in Media publications including: Videos, Email Blasts, Recruiting Brochures, Newsletters, Magazines, General Publications, Website, Affiliates and Social Media platforms. 

I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image. Please initial the paragraph below which is applicable to your present situation:

I am 18 years of age or older or am signing on behalf of my minor son or daughter, and I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release. 

Tardiness: We ask that you arrive on time for your appointments and you are considerate of the next patient’s time when your session ends. If you arrive late for your appointment, your treatment time will be shortened.

Cancellations/No Shows: To be courteous to other patients and our therapists, we ask you to please give us 24 hours notice if you are unable to keep your appointment. Failure to give 24 hours notice will result in the full charge of your missed session to your credit card. In the case that you have purchased a package with us, one of your allotted visits will be used instead of the session charge. Same-day cancelations and no-shows will also result in a full visit charge. Exceptions may be made per therapist’s discretion of true emergency.

No warranty:  I understand that Liberty Physical Therapy, LLC cannot make any promises or guarantees regarding a cure for or improvement in my condition.  Our 100% satisfaction guarantee policy applies to your satisfaction with the care you received within your first 3 visits of a purchased Plan of Care Package, not necessarily the outcome you had wished. If you are not satisfied in the care you received within the first 3 visits, talk to us about a potential refund. I understand that Liberty Physical Therapy, LLC will share with me professional opinions regarding the potential results of physical therapy treatment for my condition and will discuss treatment options with me before I consent to treatment.