MVMT Physical Therapy Intake Form

Consent to Evaluation & Treatment

I voluntarily consent to physical therapy evaluation and treatment provided by a licensed physical therapist employed by MVMT Physical Therapy LLC (“Practice”) in accordance with North Carolina law.

The nature, purpose, expected benefits, and potential risks of treatment will be explained to me. I understand that physical therapy may involve therapeutic exercise, manual therapy, neuromuscular re-education, modalities, dry needling (if applicable), and other interventions deemed appropriate.

I understand that risks may include, but are not limited to:

• Temporary soreness

• Symptom exacerbation

• Strains or sprains

• Dizziness or falls

• Skin irritation

• Rare but unforeseen complications

  
  

No guarantees have been made regarding outcomes.

I understand I may ask questions at any time and may withdraw consent in writing.

Telehealth Consent

If I elect to participate in telehealth services:

•  I understand telehealth involves remote communication using electronic technology.

• I acknowledge there may be risks to privacy due to electronic transmission.

• I understand technical failures may occur.

• I understand telehealth is not appropriate for emergencies. In case of emergency, I will call 911 or seek immediate medical care.

  
  

  I consent to receive telehealth services when clinically appropriate.

Financial Policy & Responsibility

Insurance Verification

I understand it is my responsibility to verify:

• Insurance benefits

• Authorization requirements

• Deductibles and out-of-pocket costs

• Network status

Verification of benefits by MVMT Physical Therapy LLC is not a guarantee of payment.

Assignment of Benefits

I authorize direct payment of medical benefits to MVMT Physical Therapy LLC for services rendered.

Patient Responsibility

I understand I am financially responsible for:

• Deductibles

• Copayments

• Coinsurance

• Non-covered services

• Denied claims

• Services exceeding policy limits

If payment is sent directly to me, I agree to remit payment promptly to MVMT Physical Therapy LLC.

Medicare Patients

If I am a Medicare beneficiary:

• I understand services may or may not be covered.

• If services are determined not medically necessary, I may be required to sign an Advance Beneficiary Notice (ABN).

• I agree to be financially responsible for services not covered by Medicare.

Cancellation & No-Show Policy

If I am unable to attend a scheduled appointment, I agree to provide at least 24 hours’ notice.

Failure to provide a 24-hour notice or failure to attend a scheduled appointment will result in a $25 late cancellation or no-show fee.

This fee is not billable to insurance and is my personal responsibility.

HIPAA Acknowledgement & Privacy Rights

I acknowledge receipt of the Practice’s Notice of Privacy Practices.

I understand that MVMT Physical Therapy LLC may use and disclose my Protected Health Information (PHI) for:

• Treatment

• Payment

• As otherwise permitted or required by law

I understand I have the right to:

• Inspect and obtain a copy of my records

• Request amendments

• Request restrictions

  
  

Requests must be submitted in writing. The Practice is not required to agree to requested restrictions.

I may revoke this authorization in writing, except to the extent action has already been taken.

Release of Information

I authorize MVMT Physical Therapy LLC to release medical and billing information necessary for:

• Insurance claims processing

• Payment collection

• Care coordination with other healthcare providers

A copy of this authorization is as valid as the original.

Electronic Communication Consent

I understand that if I choose to communicate via email, text message, online scheduling platforms (including Wix, Calendly), or online forms (including Google Forms), these third-party platforms may not provide the same level of security as HIPAA-covered systems.

By voluntarily using these platforms, I acknowledge and accept any associated privacy risks.

I may request alternative communication methods.

Minor Patient Consent

If the patient is under 18 years of age:

I certify that I am the parent or legal guardian of the minor patient and have legal authority to consent to treatment.

Liability Acknowledgment

I understand that physical therapy carries inherent risks.

I agree to inform my therapist of:

• Medical conditions

• Medications

• Allergies

• Pregnancy status

• Changes in health

To the fullest extent permitted under North Carolina law, I release MVMT Physical Therapy LLC and Anastasia Belikov from liability for injuries or damages arising from risks inherent in physical therapy treatment, except in cases of gross negligence or willful misconduct.

Patient Acknowledgment

Media Release

I understand that MVMT Physical Therapy LLC may request permission to use photographs, videos, or written testimonials for marketing, educational, or promotional purposes.

I understand I may revoke this authorization in writing at any time.