Consent To Treatment

I have presented myself to this facility for therapy treatments and consent to the care (history, physical examination, treatment, etc.) that will be provided by my therapist. I acknowledge that I have the right to refuse any treatments or procedures to the extent permitted by law. I am aware that Physical Therapy treatment utilizes hands-on techniques which require the therapist to touch my body as part of the treatment process. I am also aware that treatment may require exercise and the use of exercise equipment and understand that exercise and equipment may result in injury of illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that, could cause serious disability. I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or the conduct of the representatives, employees, managers or principals of Jordan Seda Physical Therapy, PLLC. I further understand that the practice of physical therapy is not an exact science and I acknowledge that no promises or guarantees have been made to me regarding treatment or services rendered by Jordan Seda Physical Therapy, PLLC. Therefore, I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify Jordan Seda Physical Therapy, PLLC and their representatives, employees, assigns, managers and principals from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or other wise which may arise out of my use of the equipment or participation in the treatments. I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the representatives or employees of Jordan Seda Physical Therapy, PLLC.

Payment Agreement

I hereby acknowledge that Jordan Seda Physical Therapy, PLLC is a cash-based physical therapy practice. Jordan Seda Physical Therapy, PLLC will provide a superbill as per patient request, but is NOT responsible if insurance does not cover the cost of the visit. Therefore, I accept full financial responsibility for, and agree to pay, all charges of Jordan Seda Physical Therapy, PLLC. I understand that no refunds will be issued. All charges are due and payable upon receipt of the bill. If payment is not made within 30 days of the receipt of the bill, a delinquent charge or interest at the maximum legal rate may be added. I hereby agree to pay all costs of collection, including reasonable attorneys’ fees.

Patient Health Privacy

I understand that Jordan Seda Physical Therapy, PLLC may 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. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the company. I also understand that the Company will consider requests for restrictions on a case by case basis, but does not have to agree to requests for restrictions. I hereby consent to the use and disclosure of my personal health information for purposes as noted in the Company’s Notice of Patient Privacy Practices. In doing so, I hereby release from any and all legal liability that may arise from the release of such information. I agree that a copy of this authorization may be used in place of the original.I understand that I retain the right to revoke this consent by notifying the Company in writing at any time except for that action which has already been taken. It shall be effective only long enough to answer the purpose of which it is given and no further confidential information will be released without the execution of an additional written authorization. I was provided access to, have read and understand the Notice of Patient Privacy Practices. 

Notice Of Privacy Practices

According to the Health Insurance Portability and Accountability Act, known as HIPAA, physical, occupational and speech therapists in private practices must incorporate the federal privacy standards to protect patient’s medical records and other health information provided to health plans, doctors, hospitals and other health care providers. Please note that Dr. Jordan Seda PT, DPT, OCS, CSCS may use your personal health information for treatment, obtaining payment, during an audit, in emergencies, or when required by law. You will be asked for written authorization to use their personal medical information for any other reason than those listed above. You have the right to review their personal health information at any time, to request that inaccurate information be corrected, or to request a list of instances when the information has been disclosed for reasons other than treatment, payment or other administrative purposes. You have the right to restrict how the information is used and disclosed for treatment, payment and administrative operations. The requests for restrictions will be considered on a case-by-case basis. You have the right to address concerns and complaints about a potential violation of their health privacy to the US Department of Health and Human Services.

For further questions, you may contact the Compliance Officer:

Dr. Jordan Seda, PT, DPT, OCS, CSCS

29 Orchard St, Apt 5D

New York, NY 10002