Embrace the Freedom With Comfort in Every Movement
Financial Responsibility
I understand my insurance plan benefits, deductibles, co-insurances, or co-payment amounts prior to any visit. Form & Focus: Rehab & Wellness is not responsible for filing any insurance claims with any private insurance companies other than Traditional Medicare Part B plans. If desired, a superbill containing the pertinent information can be provided to submit claims with my insurance carrier so I may receive reimbursement. I am aware I may not receive a full reimbursement. All co-pays/co-insurances for Traditional Medicare beneficiaries without supplemental insurance will be collected at the time of service for the anticipated amount and reconciled at time of medicare payment.
Good Faith Estimate
Service Description: This Good Faith Estimate is provided to you for the physical therapy and/or wellness services that are anticipated to be provided by Form & Focus: Rehab & Wellness. The estimate is based on the information known at the time of the estimate and may vary depending on your specific needs and the actual services provided.
Important Information:
This Good Faith Estimate provides an estimate of the total expected cost of the non-emergency healthcare items or services listed. It is not a contract and does not obligate you to obtain the services from Form & Focus- Rehab & Wellness.
The actual items, services, and costs may vary based on your individual needs and the course of treatment.
Initial Services- Sessions are 60 minutes in length.
Initial Meet & Greet ($100)
Pay-As-You-Go Session ($200)
Member Benefits
Joining a Monthly Membership Plan means you get more than just sessions — you become a priority client. Benefits include:
Priority scheduling (first pick of days/times)
Direct call or text access to your PT
Same-week rescheduling preference
Ability to bank up to 3 make-up sessions
Monthly Form Membership Plan
LSVT Big ($2,400)
3x/week ($1,800)
2x/week ($1,200)
1x/week ($600)
Monthly Focus Membership Plan
2x/month ($350)
💳 Payment Policy:
Credit Card: A 3% processing fee will be added.
Zelle: Send to: katherine@formandfocusrehab.com (Linked to Form & Focus: Rehab & Wellness)
Checks: Make checks payable to Form & Focus: Rehab & Wellness
Failed Appointment/Late Cancellation Policy
Appointments must be cancelled by 9AM the previous business day or you will be charged the full session fee rate for a failed appointment or late cancellation. This means that Monday appointments need to be cancelled by Friday at 9AM. Any charges applied will need to be paid prior to your next visit. Please note that insurance companies do not reimburse for cancelled or missed appointments and that you are solely responsible for these charges. A failure to receive an email reminder does not waive the fee. If you need to cancel your appointment, please email katherine@formandfocusrehab.com or call/text/leave a voicemail at (586) 646-8010.
Make-up sessions
If you provide a cancellation notice within a timely manner or if the physical therapist cancels your appointment in a timely manner, you can reschedule or make up that session that same week or another week, depending on availability. You can bank up to a maximum of 3 make-up sessions during your time with Form & Focus- Rehab & Wellness.
Discharge from Physical Therapy or Services
If you want to cancel or be discharged from physical therapy for the next month, please give a courtesy notice by the 15th of the previous month for optimal scheduling.
Contact Information:
Katherine Andary, PT, DPT
Form & Focus: Rehab & Wellness, PLLC
Tel: (586) 646-8010
Email: katherine@formandfocusrehab.com
Photo, Audio, & Video Release
Purpose: This photo, video, and audio Release Form is designed to obtain your consent for the use of photographs and/or videos and recordings taken of you by Form & Focus: Rehab & Wellness, PLLC for marketing, educational, documentation, and/or personal purposes.
Consent Agreement
I grant Form & Focus: Rehab & Wellness, PLLC, its representatives, and authorized personnel, the irrevocable and unrestricted right to use, reproduce, and publish photographs and/or videos of me, in whole or in part, for purposes including but not limited to advertising, social media (e.g., Facebook, Instagram), promotional materials, educational content, and any other media or format now known or later developed, without compensation.
I understand that:
These materials may be used indefinitely. My identity may be revealed through the use of images or video. The materials may be combined with other images, text, or graphics and altered as deemed necessary by Form & Focus: Rehab & Wellness, PLLC.
Release and Waiver: I release and discharge Form & Focus: Rehab & Wellness, PLLC, its employees, agents, and representatives from any and all claims, demands, or liabilities related to the use of these images and/or videos, including claims for invasion of privacy or misappropriation. I understand that I have the right to revoke this consent in writing at any time by contacting Form & Focus: Rehab & Wellness, PLLC. However, such revocation will not affect prior use or publication of materials created before the revocation was received.
Consent to Record & Use of AI Scribe for Documentation
In order to enhance the quality and efficiency of medical documentation during my care, I understand that Form & Focus: Rehab & Wellness, PLLC uses an AI- powered documentation tool, Hipposcribe, which may record audio during patient engagements.
Data Security & Confidentiality: The information collected through HIppoScribe is protected under HIPAA guidelines. Audio recordings and any patient information processed through HippoScribe are encrypted and securely stored. My health information will not be used to train or improve any AI model.
Purpose of Use:
The use of HippoScribe is intended solely to assist with documentation and accuracy.
Potential Risks:
While efforts are made to ensure data security, there is a minimal risk of transcription errors or potential data breaches.
I give my consent to the use of HippoScribe for documentation during my treatment. I understand I can withdraw this consent at any time without affecting the quality of my care.