Event Liability Waiver

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Our staff will be performing an injury screen and/or workshop where any individual who wishes to participate may. Following the injury screen/workshop, we may provide any individual with a few simple exercises and/or stretches to work on at home to reduce the risk of injury and to enhance performance, strength, and/or stability. The purpose of this injury screen/workshop is not to diagnose or treat. While the injury screen/workshop will be performed by trained individuals, participation in the injury screen/workshop carries with it a risk of injury that cannot be eliminated regardless of the care taken to avoid such injuries and the undersigned individual shall assume all risk by participating in the injury screen/workshop. By signing below, and in consideration for the aforementioned injury screen/worshop, I do waive and forever release any and all rights and claims for any damages and liabilities of any kind arising out of my participation in this injury screen/worshop, against all persons, entities, and agencies involved with performing the injury screen/workshop including but not limited to Milk and Honey Physical Therapy, and any other related individuals or entities. I understand that this injury screen/worshop is not intended to diagnose or treat any injuries, but to assist with optimizing movement for the individual. I also understand that my participation in this injury screen/workshop is not a guarantee of injury prevention or performance. The results will not be shared with any individuals or entities except as outlined herein and will only be used for informational purposes including tracking of injuries and/or trends. I also agree to being contacted by Milk and Honey Physical Therapy in the future. We will not share your personal information here onto per Milk and Honey Physical Therapy’s Privacy Policy. I have carefully read this waiver of liability and understand that I am giving up legal rights, including my right to sue. I acknowledge that I am signing this waiver freely and voluntarily and intend by my signature to be a complete and unconditional release of all liability to the extent allowed by law.

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Medicare Beneficiary Consent

Milk and Honey Physical Therapy is not and enrolled provider with Medicare or any other form of health insurance.

Services rendered in our practice are not covered by Medicare or your Secondary Insurance.

If you would like Physical Therapy to be covered by insurance or Medicare and if you have a Physician referral for such, we will be happy to recommend other providers to you who are in-network with your health plan or are enrolled providers with Medicare.

In your desire to be seen by our Doctors at Milk and Honey Physical Therapy for their expertise, we ask that you sign below to indicate that you understand that you will be paying privately for your services even if your services might be covered by your insurance or Medicare if the services were provided by an in-network or Medicare enrolled provider. You also understand that you cannot receive reimbursement from Medicare or a Medicare secondary insurance plan.

Milk and Honey Physical Therapy does not believe in discrimination against clients who are 65 and over (i.e., Medicare eligible) by turning them away if they wish to be seen, even though they have been given and considered other options that might be covered by insurance. Milk and Honey Physical Therapy would like to help you and are willing to assess your problem and administer treatments in the form of wellness advice, preventative and fitness exercises.

We would be happy to answer any questions you have regarding this matter.

Thank you for understanding.

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I understand that Milk and Honey Physical Therapy will not submit claims to Medicare on my behalf or provide me with a statement or billing codes that I can submit to Medicare myself.

I understand that if I want Medicare to pay for any services that might be considered covered benefits, I should seek those services from a Medicare enrolled provider.

By choosing to receive services from Milk and Honey Physical Therapy after being fully informed of these facts, I am agreeing to pay privately for the services I receive from Milk and Honey Physical Therapy, even if those services might be covered by Medicare if provided by a Medicare enrolled provider.

I also understand that since Milk and Honey Physical Therapy is not enrolled as a Medicare provider and the services provided do not meet the technical requirements for Medicare covered benefits, these services are not subject to Medicare’s maximum allowable charge.

I agree that I, my caregivers, family members, authorized representatives or power of attorney will not, under any circumstance, submit my claims, invoices, receipts or statements to Medicare or my Medicare Advantage Plan for reimbursement or to obtain a denial for a Medicare supplemental insurance plan.

By signing below I acknowledge, under my own free will and accord, that I would like to restrict disclosure of my protected health information (PHI) to my health plan for the purposes of payment pursuant to my rights under HIPAA because I have paid for my services privately at the time of service.