• Physical Therapy Service Agreement

  • Service Agreement

     

    THIS SERVICE AGREEMENT (this "Agreement") entered into this day of:

  •  -  - Pick a Date

  • , between Barwis Methods Physical Therapy, LLC, a Florida limited liability company and their company(s), businesses, owners, officers, subsidiaries, affiliates, employees and agents individually having a principal place of business at 525 NW Peacock Blvd., Port St Lucie, FL 34986 (“Barwis Methods" and "We"), and,

  • (hereinafter referred to as “You" or "Client").

  • Cancellations

    All cancellations of a week or more of sessions must be received with at least 2 weeks notice (14 days) or Client will be charged the entire cost of the sessions.   All cancellations of one day sessions must be received with at least 24 hours notice or Client will be charged the entire cost of the session. After the second consecutive one day cancellation, Client will be charged the entire cost of all missed sessions. 

    Client understands that Barwis Methods will make every reasonable effort to accommodate schedule requests but there are no guaranteed time slots for future training sessions and the schedule is subject to availability and change at any time.

  • Payment Methods

    Barwis Methods™ accepts payments by cash, check or credit card and requires a valid credit card number to be kept on file for payment if no alternative payment method is provided. A $25 fee will be applied for all returned checks.  Except as otherwise provided herein, there are no refunds.

  • Option to Terminate

    Barwis Methods™ reserves the right to terminate the service relationship with Client at any time, for any reason, with or without cause or notice and with no further liability to Client. No oral or written statement shall limit the right to terminate the service relationship. If Barwis Methods terminates the relationship any unused funds deposited with Barwis Methods will be returned to the Client.

  • Authorization

    Client understands that Client is personally responsible to pay all charges for services rendered to him/her and agrees to make payment thereof when due. Any billing sent by Barwis Methods™ to an insurance company, attorney, or other third party is for the accommodation of the Client and does not relieve the undersigned to pay charges for the services provided. Client authorizes any holder of medical information about him/her to release to his/her insurance carrier and his/her agents any information needed to determine these benefits. Client authorizes payment for these services to be paid directly to Barwis Methods™.

  • Medication Information Update.

    In order for us to best serve you, all clients are required to immediately notify Barwis Methods™

    of any changes in current medical condition.  Such conditions include but are not limited to blood clots, pressure sores, recent fall, any skin issues, recent bone fractures and sprains as well as any change in prescribed medications.  Depending on condition, written medical clearance may be required before reentering the program.  Client will indemnify and hold harmless Barwis Methods™ its parent companies, subsidiaries, affiliates and all employees, volunteers, directors, officers, shareholders, members, clients, and agents thereof from any claim, demand and/or cause  of action of any nature whatsoever related to any injuries sustained as a result of undisclosed medical conditions or changes in prescribed medications.

  • Third Party Billing

    Please understand that Client is ultimately responsible for payment including any remaining balance after third party coverage is applied. Although Barwis Methods may assist in contacting third parties including Client's insurance company(s) on Client's behalf, Client is ultimately responsible for the payments for services and may have to work directly with third parties for any payments and/or reimbursements to Client accounts. If Barwis Methods services are considered "out of network" by Client's insurance company(s), Client will be responsible to pay in full prior to receiving the services and will be reimbursed amounts specifically paid for by the Client's insurance company(s) in relation to the services provided to Client after Barwis Methods has received payment for such services.

  • Other Foundations, Funds, Trusts

    If payment will be made by a foundation, fund or trust, Client will need to submit invoices to the applicable party allowing enough time so that Barwis Methods will receive payments by the due date.

  • Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide Company instructions via Company's website or its affiliates, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-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 E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and Company. You also represent that you are authorized to enter into this Agreement.

  • Client:

  • Clear

  • Company:

    Barwis Methods Physical Therapy

  • By: Donnell Vanker

    Its: COO

  •    
  • Should be Empty: