NORTH CITY PHYSIOTHERAPY TERMS AND CONDITIONS

PLEASE READ THIS CAREFULLY BEFORE YOU SIGN YOUR FORM

PHYSIOTHERAPY CONSENT:

  • I hereby consent to treatment by an appropriately qualified Physiotherapist for the purpose for providing comprehensive physiotherapy services as may be necessary in support of my illness, injury or condition.
  • I understand that I have the right to decline part or all of the treatment being offered to me and that I have the right to a second opinion.
  • I have read the terms and conditions set out below, and by signing I agree to be bound by them.

AGREEMENT TO PAY:

PAYMENTS:

  •  Co-payment charges for ACC treatments or private charges including any treatment that is declined by ACC or other funder (**ACC pay part of your treatment cost and each session incurs a co-payment)
  • The costs of materials such as orthotics, materials, products, etc
  • Account administration fees ($10 per 30 days overdue) for sending outstanding account statements if I fail to pay for my appointment at the time of treatment
  • Recovery fees from any debt recovery service engaged to recover my debt

CANCELLATION & NO SHOW POLICY AGREEMENT:

We put 100% of our effort into your rehabilitation, so we hope to get 100% commitment from you. We reserve the time in our schedule specifically for you, so we ask for your cooperation by making every effort to keep and attend your scheduled appointments. No-showing or late cancelling an appointment not only affects your treatment plan and recovery, but also leaves an unpaid hole in your therapist’s schedule, and more importantly prevents other patients from getting treatment who could have utilized the time-slot. In order to achieve the best possible outcome, it’s important to attend your scheduled appointments as part of your treatment plan that we develop together.

  • Please take an appointment card, we are happy to provide you with a text message or phone reminder of your scheduled appointment, on your request.
  • If I fail to attend my appointment or cancel without 24 hours (1 day) notice I will be charged a no show fee equivalent of the ACC copayment or 50% of a private consultation

CONSENT TO RELEASE INFORMATION TO A 3rd PARTY& EMAIL ADDRESS:

We take your privacy very seriously. We may need to disclose your condition to other parties such as your doctor, or specialist.

  • I consent to the disclosure of my records to any person/organisation necessary for the effective management of my condition.
  • I consent to a discharge/progress report being sent to my doctor/specialist/medical centre if deemed necessary by us. Email Address: If you have given us your email address we may use it for the following purposes:
  • Sending you material such as your exercises, and/or any information which will be deemed beneficial for your management
  • General communication – such as appointments, your progress, etc
  • Sending you an invoice or statement of outstanding charges if they exist, as well as Debt Collection usage.
  • Sending you a feedback questionnaire at the conclusion of your treatment
  • Please opt out of our Client newsletter on the form if you wish not to receive this.

ACC DECLARATION (IF WE ARE DOING AN ACC CLAIM FOR YOU TODAY)

I DECLARE:

That the information I have given about this claim (if applicable) is true and correct and that I have not withheld any information likely to affect my application.

I AUTHORISE:

  • The collection and release of any information about me to the extent that this is needed to prevent future injuries, determine cover and/or assess my entitlement to compensation, rehabilitation assistance, medical treatment and/or the appropriate level of care and personal attention that I should receive.
  • I authorise ACC to contact anyone who holds relevant information, including any external agencies or service providers (such as medical practitioners, specialists, New Zealand Police, and Treatment Providers, IRD, WINZ, Assessment Agencies, employers and witnesses to the injury)