Office and Financial Policy

CONSENT TO TREATMENT I voluntarily consent to evaluation and treatment by KOH Physical Therapy Lab (KOHPT) and its licensed providers. Treatments may include, but are not limited to, therapeutic exercise, joint/soft tissue mobilization, manual therapy, modalities (heat, ice, ultrasound, electrical stimulation), neuromuscular reeducation, bladder training, taping, and postural/body mechanics education. I understand that the purpose, risks, and alternatives will be explained to me, and that I may refuse or discontinue treatment at any time. I may seek a second opinion or consult another healthcare provider at any time.

NONDISCRIMINATION NOTICEKOHPT complies with all federal and state civil rights laws. We do not discriminate on the basis of race, color, national origin, ethnicity, ancestry, age, sex, gender, gender identity, sexual orientation, religion, marital status, medical condition, disability (physical or mental), or genetic information.

COVID-19 WAIVER OF LIABILITY & INFORMED CONSENT By choosing in-person services, I acknowledge and assume the risk of exposure to COVID-19 or other public health risks. I authorize KOHPT staff to proceed with care under current health safety protocols in accordance with CDC and CDPH guidance.

NOTICE OF PRIVACY PRACTICES This notice explains how your medical information may be used or disclosed and your rights regarding that information. KOHPT complies with the Health Insurance Portability and Accountability Act (HIPAA). For full details, you may request a printed or digital copy.

We use your information for treatment, billing, healthcare operations, and as required by law. Access to your records is limited to necessary personnel. Requests for records must be made in writing and accompanied by valid photo ID.

Understand your health record and information: When receiving physical therapy services from KOHPT, a record is made of your treatment. This record contains your symptoms, diagnoses, examinations, assessments, evaluation, and your treatment plan. It also contains daily treatment notes and progress notes.

Our pledge regarding medical information: We understand that your medical information is personal and private. We are committed to protecting your information. Medical records are only disclosed in a limited amount of circumstances which may be regarding; treatment, payment, review for quality of care, federal, state, or local law, and lawsuits/disputes. If for any reason, you would like a copy of your entire record, please make your request in writing. For your protection, please have a proper ID with you if picking up records in the office.

ELECTRONIC COMMUNICATION CONSENT I consent that KOHPT can provide their services and communicate with me via mobile phone, messages, e-mail and any kind of online communications, provided that these communications comply with privacy regulations.

APPOINTMENT COMMUNICATION I consent to be contacted regarding appointments, changes, or reminders via phone or third-party automated systems. I acknowledge this as a courtesy and remain responsible for my scheduled appointments. I may opt out at any time.

DIRECT ACCESS NOTICE (NO PRESCRIPTION) Under California law, patients may receive physical therapy without a physician referral for up to 45 calendar days or 12 visits, whichever comes first. Continued treatment beyond this limit requires a signed plan of care by a physician who has examined the patient in person.

MEDICARE PATIENTS Medicare patients must have a valid physician referral and updated plan of care every 30 days. Failure to obtain this may result in claim denial. You are responsible for services not covered by Medicare. KOHPT will submit claims on your behalf, but you are responsible for remaining balances.

CONTACT INFORMATION You are responsible for notifying KOHPT of any changes to your contact or insurance information. You may opt out of communications at any time.

KNOW YOUR INSURANCE BENEFITS As the patient or legal guardian, you are financially responsible for all services rendered. Co-pays and deductibles are due at the time of service. KOHPT will bill your insurance as a courtesy, but benefits quoted are not a guarantee of payment. Any remaining balance after insurance processes is your responsibility. Remember benefits quoted are not a guarantee of payment.

ASSIGNMENT OF BENEFITS I hereby instruct and assign my insurance carrier to KOH PT for the professional/medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I hereby authorize said assignee to release all information necessary to secure the payment, via fax transmittal or hard copy. Medical records will be accessible to all therapists of KOHPT.

FINANCIAL POLICY KOHPT charges reasonable fees based on prevailing rates in our region. Your insurance provider may apply different definitions of “usual and customary” fees. You are responsible for any balance not covered by your plan.

CONCIERGE SERVICES All concierge services and packages are non-refundable and non-transferable, and cannot be paused or extended, whether you are on a monthly or annual membership/package. Please note that these services are not covered by your insurance carrier, and no exceptions can be made. Concierge packages renew on the anniversary date, not the calendar date. Please note that all monthly and annual concierge packages are set to renew automatically, and your account will be charged accordingly unless we receive your cancellation request at least 7 days prior to the renewal date. For detailed concierge terms and policy.

MEDIA WAIVER I hereby give my consent to KOHPT the absolute and unrestricted right and permission to take my photo, audio, and video, to reproduce, distribute and display my image, likeness, name and any other identifying characteristics, for all business, education, and marketing purposes, including but not limited to advancing KOHPT services and programs. I expressly release KOHPT from any and all claims whatsoever in connection with the use and reproduction of my image, voice, likeness, name or any other identifying characteristics in the above mentioned materials. I understand that there is no compensation for the use of the audio, photos, and/or videos of me. Unless otherwise noted the form will be valid for the lifetime of its existence. I understand that I may opt-out at any time and need to request in writing.  ☐ YES (Consent) ☐ NO (Decline)

INSURANCE DENIALS / NON-PAYMENT KOHPT is not responsible for denied or delayed payments due to outdated or incorrect insurance information. If claims are delayed beyond 90 days, the patient must pay the balance and may be reimbursed once payment is received. A 10% finance charge applies to accounts 60+ days past due. Collections, attorney fees, or additional charges may be applied if the account is turned over for collection.

ARBITRATION PROVISION Any dispute, claim or controversy arising out of or relating to this Agreement or the breach, termination, enforcement, interpretation or validity thereof, including the determination of the scope or applicability of this agreement to arbitrate, shall be determined by arbitration in Orange County, California, before one arbitrator. The arbitration shall be administered by JAMS pursuant to its Comprehensive Arbitration Rules and Procedures. Judgment on the Award may be entered in any court having jurisdiction. This clause shall not preclude parties from seeking provisional remedies in aid of arbitration from a court of appropriate jurisdiction. Allocation of Fees and Costs: The arbitrator may, in the Award, allocate all or part of the costs of the arbitration, including the fees of the arbitrator and the reasonable attorneys’ fees of the prevailing party. 

APPOINTMENT POLICY It is our policy at KOH Physical Therapy, Inc. to provide flexibility and understanding when a patient is unable to attend a scheduled appointment. However, in order to maintain continuity of care and ensure appointment availability for all patients, the following policy is in place:

Patients are encouraged to notify us as soon as possible if they are unable to attend a scheduled appointment. Appointments canceled with less than 24 hours’ notice or missed without notice (“no-shows”) may be subject to an $80 incidental charge. This fee is not covered by insurance and is considered the patient’s sole financial responsibility. It must be paid directly to the clinic.

After two (2) consecutive no-shows or late cancellations, you will be placed on a flex schedule. This means that while we are happy to continue your care, we will no longer reserve standing or advance appointments. You will need to call the day before or the same day to inquire about openings. This change is intended to support better adherence to your plan of care, as multiple missed visits can compromise treatment progress and limit appointment availability for other patients.

After three (3) total missed or short-notice cancellations, we reserve the right to place your treatment plan on hold and to notify your referring physician. Reinstatement of regular appointments may require a reassessment of your care plan and compliance expectations.

We understand that emergencies can happen and will take circumstances into consideration on a case-by-case basis. Your commitment to attending your appointments, being punctual, and following your home exercise program is essential to achieving your recovery goals.

Appointment reminders via text or email are a courtesy only; patients are fully responsible for managing their scheduled appointments. Future appointment access may be restricted until any outstanding incidental charges are resolved. We are happy to provide a print out of your future appointments. You are fully responsible for all scheduled appointments. Thank you!

AGREEMENT FOR CREDIT CARD TRANSACTIONS It is our policy to obtain credit card information to facilitate seamless payment processing. By signing below, you authorize us to securely store and charge your credit card on file for any outstanding balances, including but not limited to co-pays, coinsurance, deductibles, or late cancellation fees incurred during your scheduled appointments. Your payment at each visit is an estimate based on information provided by your insurance carrier. For confirmation of actual patient responsibility, please refer to the Explanation of Benefits (EOB) from your insurer. In the event of an overpayment, we will issue a refund for the difference. If you need to update your credit card information, please notify us. If you require a receipt for your payments, please ask each time, and we will be happy to provide one. 

Security & Privacy
Your credit card information is securely stored in our encrypted, HIPAA-compliant system, ensuring the highest level of data protection. We do not disclose your credit card information to any third parties.

Good Faith Estimate (GFE) Notice
If you are uninsured or choose not to use your insurance, you have the right to receive a Good Faith Estimate (GFE) of the expected charges for your physical therapy services. The estimate will outline anticipated costs, but final charges may vary based on your actual treatment needs. If your billed charges exceed your GFE by more than $400, you may have the right to dispute the charges under federal law. For questions regarding your GFE, please contact our office before your scheduled treatment. We can provide a copy upon your request.

As the authorized personnel listed below, I hereby authorize KOH Physical Therapy, Inc. to keep my credit card information on file, which includes the account number, CV Code, expiration date, and billing zip code associated with the credit card. I understand that I am required to provide my credit card information at the time of service. I have read and understand the above agreement.    

I have read and understand the above agreement, including my rights under the Good Faith Estimate policy. I approve KOH Physical Therapy, Inc.  to charge my credit card on file regarding any payments that I owe which consist and are not limited to invoices, physical therapy treatment sessions, and any balances that I may owe.