1) Payment; Billing.
a) If Patient is paying for services with cash, Patient understands that they are directing Company not to utilize insurance benefits, Company will not be filing with insurance, and Patient will be directly responsible for the agreed upon cash payments;
b) If Patient is using insurance for services rendered, Patient understands that the services are to be billed based on the insurance information provided and it is Patient's responsibility to alert Company of any changes to coverage as well as to ensure accuracy of information provided;
c) Patient understands that while insurance may be billed, the Patient assumes full responsibility for any unpaid outstanding balance due;
d) Patient understands there is a $50 late cancellation fee if Patient cancels within 24 hours of scheduled appointment or if Patient fails to show up for their appointment;
e) Upon, acceptance of a quote, the quote will be valid thirty (30) days. Beyond thirty (30) days, Company reserves the right to requote for the scope of work unless the delay was caused solely by the Company;
f) The Company reserves the right to end any contract at any time. Services which have been provided and costs which have been incurred will be billed appropriately. Any services which have been paid for but not provided, may be carried out to completion or simply refunded at the sole discretion of Company. Patient understands refunds will only be issued at the sole discretion of Company;
2) Patient Warranty and Indemnification of Company.
a) Patient represents that they have a condition requiring physical therapy intervention and consents to such care as necessary to address that condition.
b) Patient hereby makes representation and warranty there exists no undisclosed injury or ailments that would create a dangerous situation or environment for the services contemplated herein, other than what has been made known to Company in writing, and further warrants that Patient will notify Company of any variance in pain levels throughout treatment;
c) Patient represents and warrants Patient understands that due to the nature of the business and services to be rendered, injuries can occur and there are certain inherent risks involved with physical therapy and the Patient agrees to indemnify Company from liability except in situations of gross negligence on behalf of Company;
d) Patient understands that response to physical therapy intervention can vary from person to person and Company does not guarantee the treatment will resolve the condition Patient is seeking treatment for and Patient also understands that there is a possibility that physical therapy treatment may result in aggravation of existing symptoms;
e) Patient warrants that they assume the responsibility to alert Company of any changes in medical condition or medications as they may necessitate change in treatment;
f) Patient authorizes Prosper Physical Therapy Specialists staff to perform appropriate treatment and procedures as necessary for Patient's diagnosis and Patient understands that Patient's physical therapy treatment may be provided by a physical therapist or a physical therapy assistant;
g) Patient assigns any and all medical benefits to which they are otherwise entitled, to include any major medical, private insurance and third-party payers to Prosper Physical Therapy Specialists;
h) Company is not liable for any damages other than when Company acts with gross negligence or intentional acts. Patient understands without this warranty, the services contemplated would not be possible. Company’s liability to Patient will be limited to a maximum of the amount paid for services rendered;
3) Waiver. No waiver of any right or remedy with respect to any occurrence or event shall be deemed a waiver of such right or remedy with respect to such occurrence or event in the future. No waiver of any of Patient's obligations under this Agreement shall be effective unless in writing and signed by Company.
4) Release of Information. Patient authorizes Company and its associated health professionals to collect Patient's personal and medical information as documented above. In addition, Patient authorizes Company and its associated health professionals to communicate with Patient's family doctor, insurance providers, to refer patient to a provider, and/or referring doctor as deemed necessary for Patient beneficial treatment. Patient also understands that Patient's personal and medical information is confidential and will only be disclosed to third parties with Patient permission.
5) Severability of Agreement. If any provision of this Agreement shall for any reason be held to be invalid or unenforceable, such decision shall not affect, impair or invalidate the remainder of this Agreement but shall be confined in its operation to the provision of this Agreement directly involved in the controversy in which the decision was rendered. If the invalid or unenforceable provision cannot be reformed, the other provisions or applications of this Agreement shall be given full effect, and the invalid or unenforceable provision shall be deemed omitted.
6) Assignment. This Agreement shall inure to the benefit of and be binding upon the Company, its successors and assigns, including without limitation any entity which may acquire all or substantially all of the Company’s assets and business or into which the Company may be consolidated or merged, and the Patient, its heirs, executors, administrators and legal representatives and its successors and assigns. Patient may not assign or otherwise in any manner transfer any of its obligations under this Agreement.
7) Force Majeure. Each party shall be excused for the period of any delay and shall not be deemed in violation with respect to the performance of any of the terms, covenants and conditions of this Agreement when prevented from so doing by force majeure, except for Patient's duty to pay. The term “force majeure” means: fire, flood, extreme weather, labor disputes, strike, lock-out, riot, acts or threats of terrorism, government interference (including regulation, appropriation or rationing), unusual delay in governmental permitting, unusual delay in deliveries or unavailability of materials, unavoidable casualties, Act of God, pandemic events like COVID-19 or other causes beyond the Company’s reasonable control. Patient herby agrees Patient will still make all payments when originally due. Company will make every commercially reasonable effort to reschedule or modify to honor this Agreement in regard to the Patient event in the case of a force majeure circumstance.
8) Dispute Resolution. The parties agree that this Agreement shall be governed and construed by the laws of the state of North Carolina (without giving effect to conflict of laws principles). The parties agree that all claims or disputes arising between the parties bound by this Agreement which relate to this Agreement or the breach thereof shall be submitted to one arbitrator for binding arbitration in Raleigh, North Carolina, which arbitration shall be conducted by the American Arbitration Association and in accordance with its Commercial Arbitration Rules. This specifically excludes other methods of dispute resolution, including but not limited to, disputing charges with any credit or debit card processing company such as Visa or MasterCard. Notwithstanding the foregoing, either party may bring an injunction proceeding before a court of equity in the event that damages for a breach are not likely to be an adequate remedy, such proceeding to be brought in a judicial district that includes Raleigh, North Carolina, and the parties hereby consent to the jurisdiction of such court. The award rendered by the arbitrator shall be final, and judgment may be entered upon it in accordance with applicable law in any court having jurisdiction thereof. The provisions of this Agreement to arbitrate and any other written agreement to arbitrate referred to herein shall be specifically enforceable under the prevailing arbitration law of North Carolina.
9) Waiver and Limit of Certain Damages. Except as prohibited by law, each party hereto hereby waives any right it may have to claim or recover any special, exemplary, punitive or consequential damages. The amount of any damages claimed by Client against Company shall be, at a maximum, in the amount of the invoices paid for such services.
10) Indemnification. The Patient will, at their own expense, defend, indemnify, and hold Company, its
agents, and employees harmless from any and all claims, actions, liabilities, injuries, damages, losses,
grants, costs, and expenses, including attorney fees, arising out of or in connection with any services
contemplated in this Agreement, notwithstanding the above provision, Company shall not be
indemnified in cases of gross negligence or intentional malicious conduct.
11) Counterparts. This Agreement may be executed in one or more counterparts, each of which shall for all purposes be deemed to be an original and all of which shall constitute the same instrument. Any such counterpart may be signed digitally.
12) Entire Agreement; Amendment. The Agreement embodies the entire agreement between Company and Patient relating to the subject matter hereof. No changes, modifications or amendments of any term hereof shall be valid unless agreed upon by the parties in writing.