I give my full consent for Ascend Physical Therapy to treat me using all appropriate methods and modalities as determined by my provider. I understand that outcomes are not guaranteed and that all treatment carries inherent risks.
I acknowledge:
My provider has explained the nature, purpose, risks, and potential complications of proposed treatments.
My provider cannot anticipate every risk or complication.
I agree to notify my provider immediately if I experience unusual symptoms (GI upset, allergic reactions, etc.).
In an emergency, I will call 911.
I understand that:
Telephone consultations may be offered at the provider's discretion.
These consultations do not allow for physical or visual assessments.
If the provider deems care inadequate via phone, I agree to follow up with an in-person or video visit.
I accept responsibility for following instructions delivered via phone.
Preferred communication method: HIPAA-compliant Patient Portal.
Email communication risks include:
Messages may be forwarded, copied, or intercepted.
Email may not be read immediately—do not use for emergencies.
Email communication will become part of your medical record.
I consent to the use of email under these conditions and understand the risks. I may revoke this consent in writing at any time.
I authorize Ascend Physical Therapy to:
Use my name, phone, and email to send appointment reminders or health-related information.
Leave messages on voicemail or with individuals at my home or workplace.
I understand:
I may restrict or revoke this authorization at any time in writing.
Information already released prior to revocation cannot be withdrawn.
Ascend Physical Therapy is not liable for redisclosure of information beyond its control.
Payment
All sessions must be prepaid.
We accept cash, credit, HSA, or FSA cards.
Ascend PT does not file insurance claims but will provide a superbill.
Cancellation Policy
1st missed appointment (within 24 hrs): No fee.
2nd missed appointment: Full session charged.
3rd missed or no-show: Session charged + discharge from care + 3 referral options.
We offer grace for emergencies but do not tolerate chronic patterns of cancellation.
Voluntary Termination of Plan of Care
Refund for unused visits (minus any late cancellations within 48 hours).
Plans of care are discounted from the standard rate.
Discounts
10% off visit fees for full-time students, teachers, nurses, first responders, and military (active/veteran).
Returned Checks / Late Accounts
$20 returned check fee.
Balances over 60 days: credit card on file will be charged.
Failed charges → collection agency → additional fees and possible legal action.
Forms & Documents
Most records are available via patient portal at no cost.
Special letters/forms: $25 minimum fee.
I authorize Ascend Physical Therapy to:
Maintain my credit card securely on file.
Use it for overdue balances or approved purchases.
Provide receipts and superbills within 30 days of each visit.
We:
Adhere to federal HIPAA laws.
May revise our privacy policy with notice.
Will only use your data for treatment, payment, operations, or legal compliance.
You:
Have the right to access, amend, or request restrictions on your records.
May request confidential communication methods.
Can file a complaint if you believe your privacy rights were violated.
Contact: Dr. Jacob Tomlinson – Ascend Physical Therapy, 613 W Main Street, Suite C, Hendersonville, TN 37075 – (615) 840-0693
You have the right:
To be treated with dignity and respect
To privacy, confidentiality, and full disclosure
To participate in your care decisions
You have the responsibility:
To attend appointments or cancel at least 48 hours in advance
To provide accurate information and comply with treatment plans
To communicate questions or concerns promptly