By selecting a font below, typing my name, and clicking the “Sign Now” button, I am signing each agreement electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document.

By clicking “Sign Now” using any device, means, or action, I consent to the legally binding Terms of Use and Privacy Policy of this site(available at the bottom of this screen). I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement.

If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian. Finally, I acknowledge that I may request a copy of this signed agreement from the practice.

I intend to sign and understand that by typing my name I am accepting the terms above in their entirety.

I intend to sign and understand that by typing my name I am accepting the terms above in their entirety.

Consent

Please sign to confirm that you have agreed to authorize and direct Rise & Recover Therapy Clinics' clinicians and
assistants, as necessary to perform quality care, procedures, and treatments as deemed necessary.
The nature and purpose of the procedure/treatment, alternative methods of treatment, and potential
risks and complications will be fully explained

I acknowledge that no guarantees have been made to me as to the outcome of the procedure(s)
and/or treatment(s). I grant this consent without duress, confusion, or pressure from my physician
and/or staff, associates, or colleagues

I intend to sign and understand that by typing my name I am accepting the terms above in their entirety.

Cancellations

Please sign to confirm that you agree to provide a 24-hour notice prior to cancellation otherwise you
will be charged a cancellation fee of up to $50. In the event of skipping your appointment without
giving any notice, you understand that you will be charged the cost of the appointment ($100-$125).
These fees are your financial responsibility and cannot be billed to insurance. If the cancellation is
due to a medical reason or sickness, this fee will be waived.

I intend to sign and understand that by typing my name I am accepting the terms above in their entirety.

Acknowledgment and Authorization

Please sign to confirm that you authorize RISE AND RECOVER THERAPY LLC to bill and receive my health
insurance benefits and process the necessary information to process medical claims on my behalf.
You hereby assign your insurance benefits to be paid directly to the healthcare provider. You hereby
authorize RISE AND RECOVER THERAPY LLC to obtain/have access to your medical history.

I intend to sign and understand that by typing my name I am accepting the terms above in their entirety.

HIPPA / Privacy

Please sign to confirm that you hereby authorize RISE AND RECOVER THERAPY LLC and its affiliates, its
employees and agents, to use and disclose protected health information (e.g., information relating to
the diagnosis, treatment, claims payment, and health care services provided or to be provided to me
and which identifies my name, address, social security number, Member ID number) for the purpose
of helping me to resolve claims and health benefit coverage issues.

I understand that any personal health information or other information released to the person or
organization identified above may be subject to re-disclosure by such person/organization and may
no longer be protected by applicable federal and state privacy laws.

I understand that I have a right to revoke this authorization by providing written notice. However, this
authorization may not be revoked if its employees or agents have taken action on this authorization
prior to receiving my written notice. I also understand that I have a right to have a copy of this
authorization.

I understand that information used or disclosed pursuant to this authorization may be disclosed by
the recipient and may no longer be protected by federal or state law.
I further understand that this authorization is voluntary and that I may refuse to sign this
authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for
or coverage of services.

I have been advised of this practice’s Privacy Practices, Release of Billing Information policy,
Assignment of Benefits policy, and grant the practice Medication History Authority.

I intend to sign and understand that by typing my name I am accepting the terms above in their entirety.

Contact Authorization

Please sign to authorize the provider’s office to contact me by your mobile/home phone via call and text.

I intend to sign and understand that by typing my name I am accepting the terms above in their entirety.