I understand that in order for my trained pelvic floor physical therapist at Thrive Pelvic Health and Wellness to evaluate and treat my diagnosis, it may be appropriate to have my therapist perform a pelvic floor muscle examination. The pelvic floor exam may include an external and/or internal vaginal and/or rectal exam to assess skin integrity, coordination, reflexes, tone, scar mobility, strength, and endurance. An assessment will only be initiated after full verbal consent. I understand that I may bring a chaperone, I can stop the exam at any time, I am responsible for communicating with my attentive therapist at any and all times, and that I will ask and expect answers to any questions or concerns that I may have.
I understand that in the state of Indiana, you may have a Physical Therapy evaluation and treatment without a script. If treatment is deemed appropriate and desired after 42 days (6 weeks), a script is required to continue. This script can be from a physician, chiropractor, podiatrist, psychologist, dentist, physician's assistant, or nurse practitioner. If you are planning to submit a superbill to insurance for reimbursement, please inquire with your insurance provider to assess what may be necessary to see an out-of-network provider. Please let your therapist at Thrive Pelvic Health and Wellness know that you will be submitting a superbill prior to the initial evaluation, to ensure timely completion of the required paperwork.
I agree to pay for my treatments at Thrive Pelvic Health and Wellness at time of service, by cash, check, credit card, or HSA/FSA. I understand that it is my responsibility to call my insurance company ahead of time, and obtain any pre-authorization that is necessary, and get an estimate of my benefits. I understand that if requested, my therapist will provide me with a receipt and that it is my responsibility to submit to my insurance company.
The rates: $175 for Initial Evaluation and Treatment, $150 for Follow up Treatments, discounted packages are available upon request.
Thrive Indy PT is a cash based provider, patients with medicare cannot be seen for a service that is available via an in network provider, although can be seen for wellness only visits that cannot be submitted to insurance.
I have read and understand the above information and am agreeable to receiving care at Thrive Pelvic Health and Wellness, with an educated and credentialed Doctor of Physical Therapy. I understand that if I have any questions or concerns, I may reach out to my physical therapist to have them addressed. I consent to receiving physical therapy treatment at Thrive Pelvic Health and Wellness, and I understand that I may discontinue services at any time.