Name *

First Name

Last Name

Phone Number *

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Date of Birth *

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Address

Address 1

Address 2

City

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Name *

By typing your name, you attest that you are the person filling out this form and this acts as your signature

First Name

Last Name

Assignment of Bennefits *

I hereby assign all rights, privileges and remedies to payment for health care services to Ditmas Park Wellness LLC. I also authorize the billing manager, Meg Tyner DPT, PT, ATC, to release to government agencies, insurance carriers and all others who are financially liable for my care, all information needed to substantiate payments for care and to permit representatives thereof to examine and make copies of all records relating to such care and treatment. I have read and understand the privacy practices of the office.

I Agree

Notice of Privacy Acts *

Checking this box below indicates that you have received a copy of Ditmas Park Wellness LLC's Notice of Privacy Practices on the date indicated.

Yes

Billing and Cancellation Policy *

Checking the box below indicates that you agree to the terms: • Payment of all co pays is expected at the time of service or at the end of the week if you come for multiple treatments per week. • Fee for service is $150. In the event that your insurance does not cover this fee the responsible financial dependent will be responsible to cover the FULL fee for service. • A scheduled appointment must be cancelled at least 36 hours in advance or a $150 cancellation fee will be assessed. Similarly, if you do not show up for an appointment the $150 cancellation fee will also apply. The fee is not waived for business or travel and is not billable to any insurance carrier.

I Agree