TERMS AND CONDITIONS
Consent for Care
I hereby give my consent to Petkov Bodywork Therapy, LLC to provide care and services prescribed by my physician,
both verbally and written. I also give my consent to exercise professional judgment in any additional care and services
that may be necessary. My consent for care is extended to the said staff of the said agency providing occupational
therapy. Instructions for my care are explained to me and I understand my obligation to follow the home program and
any other recommendations given to me to the best of my ability.
I am also made aware that therapy services may result in one or all of the following: increased pain, increased
swelling, increased redness, burning sensations and wound bleeding.
Assignment of Benefits
I Thereby authorize and direct my insurance carrier (including Medicare, private insurance and any other
health/medical plan) to issue payment directly to Petkov Bodywork Therapy, LLC for medical services
rendered to myself and/or my dependents regardless of my insurance benefits, if any. It is my understanding
that any money received over and above my indebtedness will be refunded to me when my bill is paid in full. I
understand that I am responsible for any and all charges not covered by my insurance company any fees
assigned by a collection agency or an attorney. A photocopy of this assignment is to be considered as valid
as original. This will remain in effect until revoked by me in writing.
Authorization to Release Information
I hereby authorize Petkov Bodywork Therapy, LLC to (1) release any information necessary to insurance
carriers regarding my illness and treatments; (2) process insurance claims generated in the course of
examination or treatment; and (3) allow a photocopy of my signature to be used in processing insurance
claims for the period of a lifetime. This order will remain in effect until revoked by me in writing. I have
requested medical services from Petkov Bodywork Therapy, LLC. On behalf of myself and/or my dependents,
and understand that my making this request, I become fully financially responsible for any and all charges
incurred in the course of the treatment authorized.
Kindly read more about our payment policy, health policy, duties and responsibilties, disclosure policy, your rights and more at our Policy and Information page.