The boring legal stuff...
I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.
If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.
I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.
I affirm that I have notified my therapist of all known medical conditions and injuries.
I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.
I understand that massage is entirely therapeutic and non-sexual in nature.
By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.
I understand that at any time, I may withdraw my consent and the treatment or massage will be immediately stopped.
I understand that draping will be used to expose areas that require treatment
I consent to Full Range Therapy contacting me electronically
I am aware that Full Range Therapy utilizes massagebook, gsuite, squarespace and wave accounting cloud services, in which my personal information passes through and is stored on servers that may be outside of Canada according to each services privacy policies. I consent to have my information handled in this way and agree that Full Range Therapy has been sufficiently transparent with me on the topic of information privacy.
I have full understanding of the duration and cost of the treatment I have booked, and that some of the time will be used for assessment and post care consultation.
I consent to my personal and medical information being shared between the health professionals contracted by Full Range Therapy and in special cases, external health professionals and organizations to facilitate a coordinated approach to conditions that may require the involvement of multiple skilled professionals.
I consent to being charged a $25 no show fee, in the event I fail to provide Full Range Therapy a minimum of 24 hours notice of any appointment time changes or cancellation of appointment.
I agree that I am to be charged an interest rate of 14% per annum, compounded monthly, on all owing amounts currently in delinquent status. And that deliquent status is defined as amounts unpaid 3 days after receipt of invoice, from Full Range Therapy.
If I have booked a student massage, I understand that my therapist will not be fully certified and can only offer massage for relaxation purposes. Futher, I understand that student massage is not billable through insurance and I am responsible for the full payment of the services rendered. I accept that I have been sufficiently informed and waive any right to take legal action against my student therapist or Full Range Therapy, for any mistakes made during the students learning process. I understand that student services are less expensive for these listed reasons.
Consent to Collect and Exchange Personal Information (Direct Billing)
Message to the Plan member, Spouse and/or Dependent regarding Personal Information
Personal information that we collect and disclose about you, and if applicable, your spouse and/or dependents, is used by the insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering the group benefits plan, including the investigation of fraud and / or plan abuse.
Authorization and Consent
I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes. I authorize the insurer and / or plan administrator and their service provider(s) to:
use my personal information for the above purposes.
exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits or other benefits programs when relevant for the above purposes.
exchange personal information concerning any claims submitted with the plan member or a person acting on behalf of the plan member.
exchange personal information for the above purposes electronically or in any other manner.
I understand that personal information may be subject to disclosure to those authorized under applicable law.
I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan.
Additional Consent Applicable to Plan Members Only
I confirm that I am authorized by my spouse and/or dependents, if any, to disclose personal information about them to the insurer and/or plan administrator and their service provider(s) for the purposes described above and I confirm that my spouse and/or dependents also authorize the insurer and/or plan administrator and their service provider(s) to disclose information about their claims to me, for the purposes of assessing and paying a benefit, if any, and managing the group benefits plan. I also authorize my spouse and/or dependents to assign benefit payments under the plan to the healthcare provider.
In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my Plan Sponsor, for the purposes of investigation and prevention of fraud and/or plan abuse.
If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where applicable, my Plan Sponsor, for that purpose.
Benefit Assignment (Direct Billing)
I hereby assign benefits payable for the eligible claims to the Provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to the Provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the Provider for any services rendered and/ or supplies provided.
I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this Assignment, that any benefit payment made in accordance with this Assignment will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment.
I understand that this Assignment will apply to all eligible claims submitted electronically by the Provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator.
If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the Provider.