Consent, Disclosure, and Privacy
I hear-by give consent to TN Therapy Outsource, LLC and/or Premier PT and Wellness to provide the desired services, be it wellness, or massage/manual therapy/electrical or tens machine, as requested by myself, or my family member(s).
I, or my family, have provided full disclosure of any and all relevant past medical history that may impact, influence or contraindicate the prescribed service provided by TN Therapy Outsource, LLC
I understand that TN Therapy Outsource, LLC is fully licensed and its providing therapists/personal trainers are highly trained and skilled. They (TN Therapy) will ensure that the service they provide is safe, appropriate, and indicated for my wellness and condition.
While TN Therapy Outsource, LLC fully intends to give service that offers no harm, I understand that there is ALWAYS THE POTENTIAL FOR AN UNFORESEEN ACCIDENT TO OCCUR. Should this be the case, I recognize that TN Therapy Outsource, LLC has taken every necessary precaution to protect me, and therefore, I DO NOT HOLD TN Therapy Outsource, LLC liable for any unforeseen injury.
I understand that TN Therapy Outsource, LLC is a private pay company, and not contracted with any insurance companies, including Medicare. TN Therapy Outsource, LLC will not submit insurance claims for me. However, I understand that it is my right to submit invoices provided to me upon request to my insurance company. I also understand that it is my responsibility to know my insurance policy and their requirements for reimbursement. I understand that reimbursement from my insurance is not guaranteed.
TN Therapy Outsource, LLC ensures that information about me and my condition, or reason for receiving services, will remain private and be fully disclosed ONLY upon my approval.