Consent for Care by Balanced EBP, LLC

Note:  The terms “you” and “your” used below refer to the consenting patient or (if patient is under the age of 18) the patient’s consenting parent/legal guardian on behalf of the patient.

  1. CONSENT. You consent to physical therapy services at Balanced EBP LLC. You know if you have any questions about your care, you should be sure to ask the physical therapist about them. You know it is up to you to inform the physical therapist / staff about any health problems or allergies you have. You must also tell the physical therapist/staff about drugs or medications you are taking.

  2. I hereby consent to evaluation and/or treatment of my condition by a licensed physical
    therapist employed by Balanced EBP LLC.
  3. The physical therapist has fully explained to me the nature and purposes of the
    procedures, evaluation and course of treatment.
  4. The physical therapist has informed me of expected benefits and possible complications
    or discomfort, which may result from skilled physical therapy care. In addition, the physical
    therapist has explained to me the risks of receiving no treatment.
  5. I may experience an increase in my current level of pain or discomfort, or an aggravation
    of my existing injury or condition. This discomfort is usually temporary; if it does not
    subside in a reasonable time period, I agree to contact my physical therapist.
  6. I may experience an improvement in my symptoms and an increase in my ability to
    perform daily activities. I may experience increased strength, awareness, flexibility and
    endurance in my movements. I may experience decreased pain and discomfort. I should
    gain a greater knowledge about managing my condition and the resources available to
  7. The physical therapist has explained that there is no guarantee that the proposed course
    of treatment will improve my condition and that is possible, although unlikely, that the
    course of treatment may cause additional pain or discomfort or aggravate my condition.
  8. If I have trouble with any part of my treatment program, I will discuss it with my therapist.
  9. The term “informed consent” means that the potential risks, benefits, and alternatives of
    physical therapy treatment have been explained to me. The therapist provides a wide
    range of services and I understand that I will receive information at the initial visit
    concerning the treatment and options available for my condition.
  10. I have been given on opportunity to ask questions, and all my questions have been
    answered to my satisfaction.
  11. I confirm that I have read and fully understand this consent
    form. In the event of a change in medical status, I understand that my treatment may be
    modified, stopped, or referred out to the proper practitioner. I reserve the right to withdraw
    at any time.
  12. FINANCIAL. Payment is due at time of service.

  13. NO GUARANTEES. You understand that the practice of physical therapy is not an exact science and that no guarantees or promises have been made to me as a result of treatments or examinations by the physical therapist. You understand that no contract, warranty, guarantee, or promise concerning the results of the physical therapy services is made. This consent to treatment form is not a contract, nor is it an offer to contract, nor is it an acceptance of an offer to contract.

  14. NOTICE OF PRIVACY PRACTICES. You have read the Notice of Privacy Practices of Balanced EBP LLC (located below) and you understand that a copy of the notice will be provided to you upon your request.

  15. CANCEL / NO SHOW / LATE POLICY. If you must cancel your scheduled appointment, a 12-hour notice is required. No-shows or Cancels with a less than 12-hour notice will result in a fee equal to 50% of treatment fee. No-shows will result in a full visit fee.

Consent and Notice for Electronic Communication


  • “Electronic signature” means an electronic sound, symbol, or process attached to or logically associated with a record and executed or adopted by a person with the intent to sign the record.

  • “Record” means information that is inscribed on a tangible medium or that is stored in an electronic or other medium and is retrievable in perceivable form.

  • “Transaction” means an action or set of actions occurring between two or more persons relating to the conduct of business, commercial, charitable, or governmental affairs.

Note:  The terms “you” and “your” used below refer to the consenting patient or (if patient is under the age of 18) the patient’s consenting parent/legal guardian on behalf of the patient.  

  1. ELECTRONIC SIGNATURE AGREEMENT. By selecting the “I Accept eCommunications” button, you are signing this Agreement electronically. You agree your electronic signature (hereafter referred to as “eSignature”) is the legal equivalent of your manual signature on this Agreement. By selecting “I Accept eCommunications” you consent to be legally bound by this Agreement’s terms and conditions. You further agree that your use of a keypad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide Balanced EBP LLC information via the internet, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature, acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your eSignature and that the lack of such certification or third party verification will not in any way affect the enforceability of your eSignature or any resulting contract between you and Balanced EBP LLC. You also represent that you are authorized to enter into this Agreement for all persons who own or are authorized to access any of your accounts and that such persons will be bound by the terms of this Agreement. You further agree that each use of your eSignature in obtaining a Balanced EBP LLC service constitutes your agreement to be bound by the terms and conditions of Balanced EBP LLC as they exist on the date of your eSignature. 

  2. CONSENT TO ELECTRONIC DELIVERY. You specifically agree to receive and/or obtain any and all Balanced EBP LLC-related “Electronic Communications” (defined below) via the internet, text, and email. The term “Electronic Communications” includes, but is not limited to, any and all current and future notices and/or disclosures that various federal and/or state laws or regulations require that we provide to you, as well as such other documents, statements, data, records and any other communications regarding your relationship with Balanced EBP LLC. You acknowledge that, for your records, you are able to use the internet to retain Electronic Communications by printing and/or downloading and saving this Agreement and any other agreements and Electronic Communications, documents, or records that you agree to using your eSignature. You accept Electronic Communications provided via the internet as reasonable and proper notice, for the purpose of any and all laws, rules, and regulations, and agree that such electronic form fully satisfies any requirement that such communications be provided to you in writing or in a form that you may keep. 

  3. PAPER VERSION OF ELECTRONIC COMMUNICATIONS. You may request a paper version of an Electronic Communication. You acknowledge that Balanced EBP LLC reserves the right to charge you a reasonable fee for the production and mailing of paper versions of Electronic Communications. To request a paper copy of an Electronic Communication contact Balanced EBP LLC. 

  4. REVOCATION OF ELECTRONIC DELIVERY. You have the right to withdraw your consent to receive/obtain communications at any time. You acknowledge that Balanced EBP LLC reserves the right to restrict or terminate your access to his website’s scheduling and payment services if you withdraw your consent to receive Electronic Communications. If you wish to withdraw your consent, contact Dr Scott A. Jones. 

  5. VALID AND CURRENT EMAIL ADDRESS, NOTIFICATION AND UPDATES. Your current valid email address is required in order for you to obtain scheduling and billing services from Balanced EBP LLC. You agree to keep Balanced EBP LLC informed of any changes in your email address. You may modify your email address by submitting a written request to Balanced EBP LLC, visit his work location or submit an email to him.  may notify you Balanced EBP LLCh through email when an Electronic Communication or updated agreement pertaining to his services is available. Balanced EBP LLC may also use his website services for Electronic Communications. It is your responsibility to use his website regularly to check for Electronic Communications and to check for updates to this Agreement. 

  6. HARDWARE, SOFTWARE AND OPERATING SYSTEM. You are responsible for installation, maintenance, and operation of your computer, browser and software. Balanced EBP LLC is not responsible for errors or failures from any malfunction of your computer, browser or software. Balanced EBP LLC is also not responsible for computer viruses or related problems associated with use of an online system. 

  7. CONTROLLING AGREEMENT. This Agreement supplements and modifies other agreements that you may have with Balanced EBP LLC. To the extent that this Agreement and another agreement contain conflicting provisions, the provisions in this Agreement will control. All other obligations of the parties remain subject to the terms and conditions of any other agreement.

Notice Of Privacy Policy

Note:  The terms “you” and “your” used below refer to the consenting patient or (if patient is under the age of 18) the patient’s consenting parent/legal guardian on behalf of the patient.  The terms “we” and “our” used below refer to Balanced EBP LLC.


  1. We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations.

  2. We may disclose your health information to notify or assist in notifying a family member or another person responsible for your care about your medical condition or in the event of an emergency or/of your death.

  3. As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.

  4. We may disclose your health information in the course of any administrative or judicial proceeding.

  5. We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.

  6. We may disclose your health information to coroners or medical examiners.

  7. It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.

  8. We may disclose your health information for military, national security, prisoner and government benefits purposes.

  9. We may leave a message on an automated answering device or person answering the phone for the purposes of scheduling appointments. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment.

  10. In the event that we are sold or merged with another organization, your health information/record will become the property of the new owner.

  11. You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that we are not required to agree to the restriction that you requested.

  12. You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.

  13. You have the right to inspect and copy your health information.

  14. You have a right to request that we amend your protected health information. Please be advised, however, that we are not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.

  15. You have a right to receive an accounting of disclosures of your protected health information made by us.

  16. You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.

  17. We reserve the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, we are required by law to comply with this Notice.

  18. We are required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact us by calling  this office. If our Privacy Officer is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

  19. Complaints about your Privacy rights, or how we have handled your health information should be directed to our Privacy Officer by calling this office. If our Privacy Officer is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

  20. If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

DHHS, Office of Civil Rights
200 Independence Avenue, SW
Room 509F HHH Building
Washington, DC 20201

About Phil

Phil Plisky

I want to change peoples lives through dialogue about creating an ideal career, injury prevention research, and return to activity testing.

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