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Patient Forms (online, e-sign at bottom of page)

Direct Performance Physical Therapy is your home for excellence in physical therapy, where individualized programming, movement quality and a return to activity are emphasized.

To ensure that excellence is provided to every one of our patients please read and agree below to our consent and expectations from the patient. 


CANCELLATION/ NO SHOW POLICY: Appointments which are missed, rescheduled, or cancelled less than 24 business hours in advance will result in a charge to you in the full amount of the service you were scheduled for. Cancellations may be done via email or phone or text. 

A cancellation waiting list is used.  The earlier that you give our therapists notice of your need to cancel, the earlier that we can offer that appointment time to another patient.  This is important as you might benefit from this service yourself at some point.  Please keep in mind that not keeping appointments and failing to give adequate notice, affects not only Direct Performance PT, but also the other patients on our roster who might like to be seen.

Though the scheduling program is automated to send a reminder email, there can sometimes be a glitch in the system.  It is the patient's responsibility to know when the appointment is, to check with the clinic to confirm if needed, and to arrive on time. 

Note that if late cancellations or late arrivals to scheduled appointments become a chronic occurrence, we reserve the right to cancel upcoming appointments and offer them to patients who are committed more clearly to physical therapy.  Special cancellation circumstances will be considered. 

Notice to All Patients: You are responsible for your balance accrued at Direct Performance Physical Therapy, LLC (DPPT) regardless of insurance coverage. We will try our best to be transparent about your expected costs, however at times we will be misinformed on your coverage. As these times, you are still fully responsible for your balance. In addition, DPPT will hold your card on file to make it faster to process your payments and will use saved card to collect any outstanding balance if necessary after reaching out to you beforehand; this includes any cancellation fees.  

Consent For Treatment: I consent to the evaluation and treatment by DPPT. I understand, as a patient, I am under the care and control of my physician(s) and/or DPPT and that DPPT is not liable for any act or omission when providing treatment. I acknowledge that no guarantee or assurance has been, or can be made by DPPT as to the result of the prescribed treatment. By signing this agreement, I consent to have DPPT provide the treatment and care prescribed by DPPT or by my physician. I understand this consent may be revoked by me at any time.

Patient Attestation Form/ Direct Access:  I am NOT under the care of a doctor of medicine, osteopathy, chiropractic, podiatry, licenses nurse practitioner, or license physician assistant for the symptoms that I wish to seek physical therapy care for at this time. I understand that the practitioner named above will be provided a copy of my initial evaluation and patient history within 14 days. I hereby consent to the release of my personal health and treatment records to the practitioner named above

Notice of Privacy Policies: We keep our patients’ financial and health information private as required by law, accreditation standards, and our own policies. This notice explains your rights, our legal duties, and our privacy practices. We use physical, technical, and procedural methods to protect your private information. We share it only with our employees and affiliates who need it to provide service on your account, to do billing, or for other legally allowed or required purposes. Please review these policies carefully. YOUR FINANCIAL INFORMATION We collect and use several types of financial information to carry out billing and insurance activities. This may include your demographic, insurance,and coverage information, as well as that of your family. We keep records about your business with our affiliates, others, or ourselves, such as, insurance coverage, premiums, and payment history. YOUR HEALTH INFORMATION We only collect, use, and/or communicate information about you for healthcare treatment, payment, operations, or when allowed or required by law to do so. We may use your protected health information for the following: FOR TREATMENT: We use and disclose information about your personal health information within our treatments and treatment documentation. We may share this information with your referring medical provider. FOR PAYMENT: We use and disclose information about you to manage your account or benefits and may submit your protected health information to your insurance company, adjustor, lawyer, or other, as indicated by you. FOR HEALTH CARE OPERATIONS: We may use and disclose information about you within the scope of the practice to better our services and improve operations. AS ALLOWED OR REQUIRED BY LAW: Information about you may be shared with regulators for audits, licensure, or other proceedings; for administrative or other legal proceedings; to public health authorities; or to law enforcement officers, such as to comply with a court order or a subpoena. AUTHORIZATION: We will obtain your written permission before we use or share your protected health information for any other purpose, unless otherwise allowed or required by law. You may withdraw this permission anytime in writing. We will then stop using your information for that purpose. However, if we have already used your information based on your authorization you cannot take back your agreement for those past situations.  YOUR RIGHTS Under privacy regulations as of April 14, 2003, you have the right to: RECEIVE a copy of the information that we have about you, or correct personal information that you believe is missing or incorrect. If someone else (such as your doctor) gave us this information, we will tell you who, so that you can ask them to correct it. ASK us not to use your health information for payment or health care operation activities. If you make this request, it will remain your responsibility to provide required information to your payment provider. We are not required to agree to these requests. RECEIVE a list of disclosures of your health information that we make on or after April 14, 2003, except when: you have authorized the disclosure; the disclosure is made for treatment, payment, or healthcare operations; The law otherwise restricts the accounting. ASK us not to communicate with you about health matters using reasonable alternative means or a different address, if communication to your home address could endanger you. COMPLAINTS If you believe we have not protected your privacy, you can file a complaint with us or with the federal government. We kindly request notice of your complaints so that we may better serve you and other patients. We will not take action against you for filing a complaint. COPIES AND CHANGES You have the right to receive another copy of this notice at any time. Even if you agreed to receive this notice electronically, you are still entitled to a paper copy. We reserve the right to change this notice. A revised notice will apply to information we already have about you as well as any information we may receive in the future. We are required by law to comply with whatever privacy notice is currently in effect. We will communicate any changes to our notice through mail and/or our website. CONTACT INFORMATION If you want to exercise your rights under this notice, wish to talk with us about privacy issues, or to file a complaint, please contact the office directly: 757.742.3778. PATIENT ACKNOWLEDGEMENT FOR USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION I hereby acknowledge that Direct Performance Physical Therapy, LLC has the right to use my protected health information for the above governed approved applications.

Online Patient Form
I HAVE READ AND ACKNOWLEDGE THE 'Notice to All Patients' AND 'Consent for Treatment'
I HAVE READ AND ACKNOWLEDGE THE 'Patient Attestation Form/ Direct Access'

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Save time! Safely share insurance card (front & back) & Driver's License ID
***Please try to include as 1 combined file***

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