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:

  • IF YOU ARE AN ORA TOA (MUNGAVIN, CANNONS CREEK, TAKAPUWAHIA) OR PORIRUA UNION HEALTH REGISTERED PATIENT THERE IS NO SURCHARGE FOR IF YOU HAVE AN APPROVED ACC CLAIM. THIS ONLY APPLIES WHEN YOU ARE SEEN IN OUR PORIRUA CLINICS ONLY, NOT ANY OTHER NORTH CITY PHYSIO CLINICS.
  • IF YOU ARE NOT AN ORA TOA OR PORIRUA UNION HEALTH REGISTERED PATIENT, NOTE THAT ACC DOES NOT COVER THE FULL COSTS OF TREATMENT. THERE IS A CO-PAYMENT THAT YOU MUST PAY FOR EACH TREATMENT SESSION THAT YOU HAVE.
  • ALL PATIENTS are liable to pay the costs of materials such as taping, orthotics, materials, bandages etc. We will inform you of these costs before you incur them.
  • We do not operate a credit policy and you must pay for your treatment or materials at the time that your receive it or you may be charged an administration fee, interest and/or debt recovery fees.
  • You are liable for all payments due that are DECLINED by ACC or any other funder/insurer.

NO SHOW AND CANCELLATIONS:

  • 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 you fail to attend or you cancel your appointment within 24 HOURS of the scheduled appointment time, you will be charged a non-attendance fee of $30.00.
  • We reserve the right to discharge you from our service for repeated no shows or late cancellations.

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)