Please have your insurance policy information available to complete all fields in this form.
Please upload a file
For families without insurance, we do offer self-pay rates and have financial assistance available. Please see the Financial Aid Policy & Application on our website and contact us for details.
I authorize our insurance benefits to be paid directly to JS Therapies. I also authorize JS Therapies or our insurance company to release any information required to process our claims. I agree to pay denied by my insurance carrier, including, but not limited to: non-covered services, deductibles, co-pays, and services exceeding maximum benefit limits. I shall promptly notify JS Therapies of any changes in Insurance coverage.
Please specify if there are any days/times you are NOT available.
CONSENT FOR CARE AND TREATMENT: I hereby grant permission for the therapists at JS Therapies, LLC to provide routine therapeutic care, including evaluations, therapeutic/educational activities, & other procedures and/or treatments prescribed by my therapist as is necessary in their judgment.
ACKNOWLEDGEMENT OF PRIVACY PRACTICES: I acknowledge that JS Therapies, LLC will use & disclose my personal health information for treatment, payment, & other healthcare operations and as otherwise permitted by law. I understand that I may request a copy of the Notice of Privacy Practices to provide further detailed information about how my protected medical information is used or disclosed.
RELEASE OF INFORMATION: I also allow the release of my medical information to the following individuals:
Doctor name or NO CONTACT
Family, other professionals
This authorization is valid for the duration of my treatment from the date signed below. I understand that I may revoke this authorization at any time, but will not hold JS Therapies responsible for already releasing information in good faith.