Medicare Beneficiary Disclaimer & Notice

General Informed Consent & Liability Waiver

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Informed Consent For Physical Therapy Services

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1. Consent to Evaluation and Treatment

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By signing below, I hereby authorize Lucas Witmer/Witmer Mobile Physio, a licensed physical therapist, to perform physical therapy evaluations, treatments, and/or wellness services. The physical therapist will explain the plan of care, risks and expected outcomes relative to my condition. In understand that I have the right to ask questions and refuse treatment at any time. 

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2. Mobile Practice and Environmental Waiver

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Because services are provided in a mobile capacity (ie client's home, office, or gym environment), the client agrees to provide a safe, clear, and appropriate space for treatment. I hereby release Witmer Mobile Physio and it's operators from any liability, injury, loss or property damage that occurs within my premises during the course of a mobile visit, except in cases of gross negligence.

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3. Financial Responsibility & Out-of-Network Status

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I understand that Witmer Mobile Physio does not participate with any private commercial health insurance plans, Medicaid or Medicare.

• Payment is due in full at the time of service.

• I understand that I am fully responsible for all fees and that Witmer Mobile Physio will not communicate with or bill my insurance company

• I understand that if I choose to submit a "Superbill" to my commercial insurance for out-of pocket reimbursement, success is not guaranteed and depends entirely on my insurance policy. I explicitly acknowledge that Superbills cannot be submitted to Medicare.

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Client Signiature: __________________________________________________________

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Date: ________________________________________________

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Private Wellness Agreement for Non-covered Performance and Wellness Services

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Background: Medicare covers outpatient physical therapy when it is deemed medically necessary to treat a specific medical injury or functional deficit. Medicare does not cover general fitness, prevention, independent gym programs or wellness maintenance. 

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Agreement:

I, _________________, certify that I am a beneficiary of Medicare Part B. I wish to receive non-covered athletic performance, fitness or wellness services from Witmer Mobile Physio.

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I acknowledge and understand the following:

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1. No Medically Necessary Care: The services provided under this agreement are strictly for performance, fitness, wellness, and prevention. They do not constitute "skilled physical therapy" meant to treat an active medical diagnosis or restore lost medical function.

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2. No Claims Allowed: Because these services are categorized as wellness, they are not covered by Medicare. Neither Witmer Mobile Physio nor I will submit a claim or Superbill to Medicare for these visits. 

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3. Choice of Provider: I understand that if I require skilled, medically necessary physical therapy, I have the right to see an enrolled Medicare provider who can bill Medicare on my behalf. I am choosing to pay completely out-of-pocket for performance or wellness services instead. 

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Client Signature: _________________________________

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Date: ____________________

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Federal No Suprises Act Disclosure

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As a cash-pay/out-of-network provider, federal law requires Witmer Mobile Physio to give a Good Faith Estimate (GFE) of how much your care will cost before we treat you. 

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A written document listing your exact per-session rate and the expected total cost for a typical episode of care will be provided before your first official appointment. 

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Mandatory Florida 30-Day Direct Access Clause

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Under Florida Statutes Section 486.085, a patient may receive physical therapy treatment via "Direct Access" (without a physician referral) for up to 30 days. 

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• 30-Day Limit: If my physical therapy treatment is for a condition not previously assessed by a practitioner of record, and treatment extends beyond 30 days, Witmer Mobile Physio must have my plan of care reviewed and signed by a licensed physician, chiropractor, or dentist.

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• Financial responsibility: I understand that some private health insurance companies require a physician's referral to reimburse out-of-network claims. Witmer Mobile Physio makes no guarantee that my insurance will accept a Superbill without a referral.

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Patient initials: _________

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Out-Of-Network Superbill Policy

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Witmer Mobile Physio is a 100% out-of-network provider. We do not participate in any insurance panels, nor do we engage in insurance billing, coding disputes, or claims submissions. 

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• The Superbill: Upon request, we can provide you with an itemized monthly receipt called a "Superbill." This document contains standard medical identifiers (CPT treatment codes and ICD-10 diagnosis codes).

• Client Responsibility: You are solely responsible for submitting the Superbill directly to your commercial insurance company for potential out-of-network reimbursement. All payments to Witmer Mobile Physio are due at the same time of service, regardless of your insurance company's reimbursement decisions. 

• Strict Medicare Exception: If you are a Medicare beneficiary receiving performance or wellness services, you will not receive a Superbill. Federal law prohibits the submission of superbills to MEdicare by non-enrolled physical therapists. Submitting a superbill from this practice to MEdicare constitutes an unauthorized claim. 

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Mandatory MVA Cash Pay & Attorney Disclosure

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Motor Vehicle Accident (MVA) Financial Policy Disclosure

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Thank you for choosing Witmer Mobile Physio for your recovery. Please review our specific financial policy regarding motor vehicle accidents and personal injury claims. 

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1. Immediate Cash-Pay Requirement

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Witmer Mobile Physio operates strictly as an immediate cash-pay, out-of-network provider. We do not accept Letters of Protection (LOPs), doctor's liens, or direct billing to auto insurance companies (PIP/MEdPay). Payment in full is required at the time of each mobile visit. 

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2. Superbills & Itemized Ledgers

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Upon request, we will provide you and your legal counsel with a detailed, itemized statement (Superbill) containing the standard CPT treatment codes, ICD-10 diagnosis codes, and proof of your payment. Your attorney may submit these documents to the auto insurance carrier or include them in your legal demand package for reimbursement.

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3. No Guarantee of Third-Party Reimbursement

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While we provide compliant medical documentation, Witmer Mobile Physio makes no guarantee that your auto insurance company or a legal settlement will fully reimburse you for our services. The client remains 100% financially responsible for all fees regardless of legal outcomes. 

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Patient Signature: __________________________________________

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Date: _____________________________

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Florida 14-day PIP Rule Acknowledgement

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Under Florida Statute 627.736, individuals injured in a motor vehicle accident must receive initial medical services within 14 days after the motor vehicle accident to utilize Personal Injury Protection (PIP) benefits.

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Please initial the statement that applies to you:

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________ I am within the 14-day window: My accident occurred on (Date: ____________), and I am seeking treatment within 14 days. 

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________ I have already been evaluated: My accident ocurred more than 14 days ago, but I received an inidial medical evaluation at an Emergency Room, Urgent Care, or Chiropractic/Medical office within 14 days of the accident.

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________ I am outside the 14-day window: My accident occurred more than 14 days ago, and I did not receive medical care within the first 14 days. I will understand that my auto insurance will likely deny any reimbursement claims for my care, and I freely choose to pay out-of-pocket for Witmer Mobile Physio's services without expectation of PIP reimbursement.

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Patient Signature: _____________________________

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Date: ________________________________

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Authorization For Release Of Medical Records & Health Information

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Patient Name: _______________________________________________

Date of Birth: ______________________

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I hereby authorize Witmer Mobile Physio to disclose and release copies of my physical therapy evaluations, daily progress notes, treatment plans, itemized bills, and superbills to my legal representatives listed below:

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• Law Firm/Attorney Name: ____________________________________________

• Attorney Email/Phone: _______________________________________________

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Purpose of Disclosure: Assessment and pursuit of legal claims related to a motor vehicle accident or personal injury. 

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• This authorization will remain valid until the conclusion of my legal case unless revoked by me in writing earlier

• I understand that I have a right to receive a copy of this authorization form.

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Patient Signature: ______________________________

Date: __________________________________

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Good Faith Estimate for Physical Therapy Services

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Notice to Patients: This Good Faith Estimate shows the costs of services that are reasonably expected for your health care needs. The estimate is based on information known at the time the estimate was created. It does not include any unknown or unexpected costs that may arise during treatment.

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Patient Name: __________________________________________________________________

Date of Birth: ___________________________________

Date of Estimate: ___________________________________

Provider Name: Lucas Witmer/Witmer Mobile Physio

Provider NPI:

Tax ID/EIN:

Primary Diagnosis Code (if known): ___________________

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Estimated Services & Cost Options

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Select the care tier that fits your recovery plan. All rates are inclusive of travel and mobile equipment + set-up. 

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Option A: Pay-As-You-Go Rate

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Initial Evaluation (1 visit): $225.00

Treatment Session (1 visit): $200.00

Example: (Eval + 4 sessions = $1025.00)

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Option B: Discounted Care Packages (Pre-Paid Upfront)

• Recovery Program: (Eval ($200) + 4 sessions ($190/visit) = $960.00)

  • Must be completed within 6 weeks​

• Rebuild Program: (Eval ($200) + 8 sessions (180/visit) = $1640.00)

  • Must be competed within 12 weeks​

• Return to Performance Program (Eval ($200) + 12 visits  (170/visit) = $2240.00)

  • Must be completed within 18 weeks

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• Any sessions not utilized within these timeframes will be formally forfeited. No refunds, partial refunds, or extensions will be granted for unused sessions due to client cancellation or non-compliance.

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Note: For Mobile Care, the per-visit cost includes all travel, equipment set-up, and face-to-face treatment time.

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Patient Initials: _________

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​Important Mandatory Disclosures

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Right to Dispute: If your actual billed charges from Witmer Mobile Physio exceed this Good Faith Estimate by $400 or more, federal law permits you to dispute the bill through the federal patient-provider dispute resolution process. 

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Not a Contract: This estimate is not a contract and does not obligate you to receive any of the services listed above (from Witmer Mobile Physio). You may terminate care at any time.

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No Insurance/Medicare Claims: This estimate assumes 100% out-of-pocket cash payment. These Services will not be billed to Medicare or private insurance by this provider. 

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Patient Acknowledgement:

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I acknowledge that I have received and reviewed this Good Faith Estimate prior to receiving services. 

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Patient Signiature: _____________________________

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Date: ________________________

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Pre-Paid Package Terms and Conditions

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By purchasing a discounted care package (4, 8, or 12 sessions), you agree to the following binding financial terms:

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Upfront Payment: Packages must be paid in full prior to or on the date of the first treatment session

No refunds: Package purchases are final and non-refundable. If you choose to terminate care early, unused sessions will not be refunded. 

Expiration: All sessions within a package must be utilized within 12 months of the purchase date. Any unused sessions after this period will be forfeited. 

Transferability: Sessions are non-transferable and may only be used by the client listed on the intake account. 

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Patient Initials: ______________________

 

 

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Mobile Specific Cancellation & No-Show Policy

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Mobile Cancellation, Late-Cancel, & No-Show Policy

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Because Witmer Mobile Physio provides concierge, mobile physical therapy services directly to your home or office, significant travel time and scheduling blocks are reserved exclusively for you. Late cancellations and "No-Shows" deeply impact our ability to serve other clients in need. 

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1. The 24-hour Policy Window

You must notify Witmer Mobile Physio at least 24 hours prior to your scheduled appointment time to cancel or reschedule. You may cancel via phone, text, or your patient portal. 

2. Late Cancellation Fees

• Cancellations made less than 24 hours in advance will be subject to a flat fee of $100.00.

• Package/Program Clients: Alternatively, at the providers discretion, a late cancellation may result in the forfeiture of one (1) pre-paid session from your current package instead of a cash fee.

3. "No-show" & Access Issues (Full Fee)

If the therapist arrives at your designated location and you are not present, or if the therapist is locked out/unable to gain access to the premises within 15 minutes of the scheduled start time, the visit will be considered a "No-Show."

• No-Shows will be charged the FULL cost of the scheduled visit (200.00, or the forfeiture of one package session). 

• Credit Card on File Authorization

All patients must maintain a valid credit card on file within our secure billing system. By signing below, you explicitly authorize Witmer Mobile Physio to charge your card on file for any late cancellation or no-show fees incurred, in accordance with the terms above.

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Patient signature: ___________________________________________________

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Date: ________________________________________

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Credit Card on File Authorization Form

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Credit Card Authorization & Card on File Policy

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Witmer Mobile Physio utilizes a secure, PCI-compliant electronic medical record (EMR) system to safely encrypt and store payment information. A valid credit card must be kept on file to secure your mobile appointments and facilitate seamless cash-pay workflow.

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1. Authorize Charges

By signing below, you authorize Witmer Mobile Physio to automatically charge your credit card on file for the following balance types:

• Pre-Paid Program Packages

• Pay-As-You-Go Sessions: 

• Incidental Fees: Late cancellation fees ($100) or No-Show fees (full session cost) incurred in strict accordance with out 24-hour cancellation policy

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2. Cardholder Information & Acknowledgement

• Cardholder Name (as it appears on card): ______________________________________________

• Last 4 digits of Card: ______________

• Zip Code: ___________________

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I understand that this authorization remains in effect until my episode of care is concluded or I revoke this authorization in writing. I acknowledge that card-on-file billing is a mandatory condition of receiving mobile, out-of-network care with Witmer Mobile Physio. 

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Cardholder Signature: ______________________________________________________

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Date: __________________________________

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