This acknowledgement of notice and consent authorizes Dynamic Home Therapy/Dynamic NeuroFit (DHT/DNF) to use health information about you for treatment, payment, and healthcare operational purposes.

Notice of Privacy Practices (revised 1/20): DHT/DNF has a Notice of Privacy Practices which describes how we may use your protected health information (PHI) and how you can access your protected health information. You will be given a copy of the privacy notice upon request, or you can acess t on our website at www.livedynamicnow.com.

Acknowledgement and Consent: I have reviewed the Notice for Privacy Practices for DHT/DNF, and they are authorized to use health information for (​print name below)

Please provide us with your information, along with the name of other person(s) who you would like included to whom DHT/DNF may disclose health information to below.

Please fill out your preferred phone number/option to be contacted by DHT/DNF (only need to choose ONE).

If no email address, or that of a POA, put info@livedynamicnow.com

●       I hereby consent to physical, occupational or speech therapy treatment as prescribed by my physician, or as deemed necessary by the treating therapist. The patient is responsible for charges incurred, regardless of insurance coverage. Dynamic Home Therapy/Dynamic NeuroFit (DHT/DNF) will file the claim for patient’s services to the insurance company. If the insurance company denies payment for non-covered services, deductible, copays/coinsurances, etc, I understand that I am responsible for all balances due.

●       I understand, in some instances, all or some of the applicable therapy charges billed to my insurance company may not be covered under my insurance policy. I agree to be responsible for any portion of my bill not covered by insurance. I understand that it is my responsibility to understand my insurance benefits and comply with the requirements of the policy. 

• I also agree to forward any reimbursement checks to DHT/DNF from my insurance that are mailed directly to me.

●       DHT/DNF respects patient’s time and makes every effort to arrive on schedule. However, because an employee cannot anticipate what every person will need, or if medical emergencies arise, we will take whatever time is necessary to give each and every patient the best care that is needed. As our employees make home visits, one cannot always foresee challenges with parking, heavy traffic, or unforeseen road conditions. For this reason therapists will give a window of 15-30 minutes for appointment time of arrival. If the therapist is running more than 30 minutes late, then the patient will be called in advance and given the opportunity to reschedule without a cancellation / no show fee.

●       In the event that the patient is unable to keep an appointment please contact your therapist as quickly as possible. Visits that are cancelled less than 24 hours prior to visit time, or are not cancelled at all will be billed $75.00 due to scheduling and traveling inconveniences. E-mail is a suitable means to communicate visit cancelation. In the case of a true medical emergency, the cancellation fee will be waived.

●       In the cases of multiple cancellations ( >3) for non-medical purposes, the therapist may discharge your case at their discretion.

The patient has the right to ask the therapist what type of treatment he/she is planning based on medical history, diagnosis, symptoms and testing results. The patient may ask the therapist about the potential risks and benefits of a specific treatment. The patient has the right to decline any portion of the treatment at any time before or during the treatment session.