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These Terms and Conditions (“Agreement”) are entered into and made effective as of the date of payment (the “Effective Date”) by and between Radiant Health and Wellness, PLLC, a Massachusetts professional limited liability company providing physical therapy services (“Radiant Health and Wellness” or the “Provider”), and the individual receiving physical therapy services and/or their parent or legal guardian if the individual receiving services is a minor (collectively referred to as the “Client”).
By submitting payment, the Client (and, where applicable, the Client’s parent or legal guardian) expressly acknowledges that they have read, understand, and agree to be bound by the terms of this Agreement.
If services are being provided to a minor, the parent or legal guardian entering into this Agreement represents that they have the legal authority to consent to services on behalf of the minor.
1.0 Initial Evaluation + Treatment
This Agreement takes effect immediately as of the Effective Date.
The Client’s purchase includes one (1) 60-minute Initial Physical Therapy Evaluation + Treatment appointment with Dr. Beata Harasim, PT, DPT, FAAOMPT.
The Client has ninety (90) days from the Effective Date to schedule and use the Initial Evaluation + Treatment unless otherwise expressly stated at the time of purchase or an extension is required by applicable law.
The appointment expires at the conclusion of the applicable use period unless Radiant Health and Wellness expressly agrees otherwise in writing or an extension is required by applicable law.
The Initial Evaluation + Treatment is intended to provide sufficient time for Dr. Harasim to obtain relevant history, perform an appropriate physical therapy evaluation, discuss findings, and begin treatment when clinically appropriate.
The exact evaluation and treatment provided will depend upon the Client’s presentation, needs, goals, health history, examination findings, safety considerations, professional scope, and Dr. Harasim’s clinical judgment.
Purchase of the Initial Evaluation + Treatment does not commit the Client to additional physical therapy visits or a predetermined course of care.
If continued physical therapy is recommended following the evaluation, Dr. Harasim will discuss appropriate next steps with the Client. Any additional appointments or packages are purchased separately and are subject to availability, clinical appropriateness, and the terms and fees applicable at the time of purchase.
2.0 Physical Therapy Services
Dr. Beata Harasim, PT, DPT, FAAOMPT, is a licensed physical therapist in Massachusetts and Connecticut.
Physical therapy services may include, but are not limited to:
- Physical and movement assessment;
- Musculoskeletal and neuromuscular assessment;
- Assessment of strength, mobility, balance, coordination, gait, movement patterns, and physical function when appropriate;
- Manual therapy;
- Joint mobilization and manipulation when clinically appropriate;
- Soft-tissue and myofascial techniques;
- Muscle energy techniques;
- Neuromuscular re-education;
- Prescribed movement and movement retraining;
- Therapeutic activities;
- Mobility interventions;
- Functional and/or athletic retraining;
- Education related to physical function, movement, pain, mobility, posture, recovery, activity, or other relevant physical factors;
- and Other physical therapy interventions within Dr. Harasim’s professional scope of practice.
Personalized care does not mean that every available service, modality, intervention, technique, or approach will be used.
Evaluation and treatment are individualized according to the Client’s history, presentation, needs, goals, examination findings, response to care, safety considerations, professional scope, and Dr. Harasim’s clinical judgment. No particular physical therapy intervention, technique, or treatment is guaranteed or required merely because it is listed in this Agreement or otherwise offered by Radiant Health and Wellness.
2.1 In-Person and Virtual Physical Therapy
In-person physical therapy appointments are available by appointment in:
- Agawam, Massachusetts;
and - Farmington, Connecticut.
Appointment availability varies based upon Dr. Harasim’s schedule, location availability, and other applicable factors.
Virtual physical therapy may also be available when clinically appropriate and legally permitted.
For virtual physical therapy, the Client must be physically located in Massachusetts or Connecticut at the time of the appointment, unless Dr. Harasim is otherwise legally authorized to provide physical therapy in the jurisdiction where the Client is physically located.
The Client understands that certain physical therapy services, including hands-on examination, manual therapy, and other hands-on interventions, require an in-person appointment and cannot be performed virtually.
The format and location of care will be determined based upon availability, clinical appropriateness, applicable professional requirements, and Dr. Harasim’s professional judgment.
2.2 Optional MiHealth Bioenergetic Support
When appropriate, available, and desired by the Client, eligible in-person appointments may incorporate MiHealth as an optional bioenergetic wellness tool.
MiHealth is not represented under this Agreement as a medical diagnostic tool, and its use does not constitute medical diagnosis or medical treatment.
MiHealth is not represented as physical therapy merely because it may be incorporated during an appointment in which physical therapy services are also provided.
Use of MiHealth is optional and is not required in order to receive physical therapy services.
The Client may decline or discontinue use of MiHealth at any time.
2.3 Services Not Included
This purchase is specifically for physical therapy evaluation and treatment.
Unless separately purchased and expressly agreed upon, the Initial Evaluation + Treatment does not include:
- Functional or integrative health consultation;
- Functional laboratory testing or detailed laboratory review;
- Nutrition or digestive-health consultation;
- Gut-health protocols;
- Holistic health coaching;
- Somatic, emotional, or energetic coaching;
- Ongoing health-management services;
- or Other services outside the physical therapy appointment purchased under this Agreement.
Recommendations related to products, equipment, general self-care, activity, or other resources may be provided when relevant to the Client’s physical therapy care. Such recommendations do not convert the physical therapy appointment into a broader holistic or functional-health consultation.
3.0 Payment and Fees
The Client agrees to pay the fee displayed at checkout for the Initial Physical Therapy Evaluation + Treatment at the time of purchase.
Payment is due in full at the time of purchase. The applicable fee may reflect a regular, promotional, introductory, or other limited-time rate.
The Client’s financial obligation for the purchased appointment is the amount displayed and accepted at checkout at the time of purchase.
Purchase of the Initial Evaluation + Treatment does not financially commit the Client to additional physical therapy appointments.
If additional physical therapy is recommended following the evaluation, any additional appointments or packages will be offered separately at the applicable rate then in effect.
3.1 Promotional Offers
From time to time, Radiant Health and Wellness may offer promotional rates or additional purchase opportunities subject to specific eligibility requirements, deadlines, use periods, or other conditions.
Any promotional conditions disclosed on the applicable sales page, checkout page, confirmation page, or written offer at the time of purchase are incorporated into the terms of that particular offer.
Unless expressly stated otherwise, promotional pricing does not guarantee future appointments at the same promotional rate.
3.2 Refund Policy
Except where otherwise required by applicable law, payments for the Initial Evaluation + Treatment are nonrefundable.
If the Client voluntarily decides not to use the purchased appointment, the payment does not automatically become refundable or transferable.
If Radiant Health and Wellness is unable to provide the purchased appointment or determines before providing the service that the professional relationship cannot appropriately be established, Radiant Health and Wellness may cancel the appointment and issue an appropriate refund.
4.0 Client Responsibilities
Radiant Health and Wellness’s ability to provide safe and appropriate physical therapy depends upon the Client providing accurate and complete information and participating appropriately in the professional relationship.
The Client agrees to provide accurate and complete information to the best of their knowledge and to communicate relevant symptoms, health history, diagnoses, medications, allergies, precautions, restrictions, prior procedures or surgeries, reactions, changes in health status, and other information that may affect the appropriateness or safety of physical therapy.
The Client agrees to inform Dr. Harasim if symptoms or circumstances change before or during treatment.
4.1 Scheduling, Cancellations and Rescheduling
Appointments are scheduled individually based upon the Client’s needs, preferred location, requested days and times, Dr. Harasim’s availability, and applicable location availability. Purchase of an appointment does not guarantee availability on a particular date, time, or at a particular location.
The Client is responsible for contacting Radiant Health and Wellness and making reasonable efforts to schedule the purchased appointment within the applicable use period. If the Client needs to cancel or reschedule an appointment, at least 24 hours’ notice is required.
Appointments canceled with less than 24 hours’ notice or missed without notice may be considered used and/or may be subject to the applicable cancellation fee, except where otherwise required by law or waived by Radiant Health and Wellness in its discretion.
Repeated cancellations, rescheduling, or failure to schedule does not automatically extend the applicable expiration or use period.
4.2 Communication
If the Client believes that an aspect of treatment is not working as desired, experiences an unexpected response, or has concerns regarding a recommendation or intervention, the Client agrees to communicate this with Dr. Harasim as soon as reasonably possible so that treatment may be reassessed when appropriate.
Purchase of an Initial Evaluation + Treatment does not include unlimited email, text, Messenger, social-media, or other between-appointment clinical consultation unless expressly agreed to in writing.
Communications outside scheduled appointments are intended primarily for reasonable scheduling, administrative, follow-up, or service-related purposes unless otherwise agreed.
4.3 Email Communication Consent
By purchasing physical therapy services, the Client consents to receive communications reasonably related to participation, including intake information, scheduling information, appointment-related communications, payment notices, resources, and other communications reasonably necessary to administer the professional relationship.
The Client may also receive optional educational or marketing communications and may unsubscribe from those communications where applicable. Unsubscribing from optional marketing communications does not prevent Radiant Health and Wellness from sending transactional, scheduling, clinical, payment, or other communications reasonably necessary to provide services.
4.4 Emergencies and Urgent Concerns
Radiant Health and Wellness’s private physical therapy services are not emergency medical services. Email, voicemail, text messages, social-media messages, or other routine communication channels should not be used for emergencies or urgent medical concerns.
If the Client believes they are experiencing a medical emergency, the Client should call 911, go to the nearest emergency department, or otherwise seek appropriate emergency assistance.
The Client is responsible for maintaining access to appropriate medical providers, urgent care, emergency services, and other healthcare professionals for matters outside the scope of physical therapy.
5.0 No Guarantee of Results
Physical therapy involves individualized assessment and treatment, and individual responses vary.
Radiant Health and Wellness and Dr. Harasim make no guarantee regarding any particular outcome, degree of improvement, recovery time, number of visits required, or response to treatment. Testimonials, case examples, and experiences of other Clients do not guarantee that another Client will experience the same or similar results.
5.1 Affiliate Disclosure
Radiant Health and Wellness is a participant in the Amazon Services LLC Associates Program and may participate in other affiliate programs. Some products, equipment, educational resources, or other recommendations provided to the Client may contain affiliate links. If the Client purchases a product or service through an affiliate link, Radiant Health and Wellness may receive a small commission at no additional cost to the Client. Recommendations are made based upon their potential relevance to the Client’s care, goals, or needs. The existence of an affiliate relationship does not mean that a particular product is required. The Client is free to obtain recommended products or equipment from another source when appropriate.
6.0 Insurance, Superbills and HSA/FSA
Physical therapy services provided under this Agreement are private-pay services.
Radiant Health and Wellness does not bill insurance directly.
When applicable documentation and billing requirements are met, Radiant Health and Wellness may provide a superbill to the Client for qualifying physical therapy services.
The Client is responsible for submitting the superbill to their insurance carrier and for communicating directly with their insurance carrier regarding reimbursement.
Radiant Health and Wellness does not submit superbills or insurance claims on the Client’s behalf. Submission of a superbill does not guarantee reimbursement. Insurance coverage, eligibility, deductibles, reimbursement rates, visit limitations, authorization requirements, referral or prescription requirements, medical-necessity requirements, documentation requirements, and all other coverage decisions are determined by the Client’s insurance carrier and individual insurance plan.
The Client is responsible for verifying their individual insurance benefits and requirements and for obtaining any referral, prescription, authorization, or other documentation required by their insurance plan if the Client intends to seek reimbursement.
The Client remains responsible for the full fee charged by Radiant Health and Wellness regardless of whether the Client submits a superbill or whether their insurance carrier reimburses any portion of the service.
The Client may also be able to use HSA or FSA funds for eligible physical therapy services or related healthcare expenses.
Eligibility, documentation requirements, and reimbursement are determined by applicable law and the Client’s individual HSA/FSA plan or administrator.
The Client is responsible for verifying HSA/FSA eligibility and requirements and for obtaining any referral, prescription, Letter of Medical Necessity, or other documentation required by their individual plan or administrator.
Radiant Health and Wellness does not guarantee insurance reimbursement or HSA/FSA eligibility.
6.1 Medicare
Physical therapists are subject to federal Medicare requirements governing physical therapy services provided to Medicare beneficiaries.
Radiant Health and Wellness does not represent this private-pay arrangement as an alternative means of privately contracting for physical therapy services that are required to be billed to Medicare.
If the Client is a Medicare beneficiary, the Client agrees to contact Radiant Health and Wellness before purchasing or receiving services so that the appropriateness of the private-pay service can be determined based upon the nature of the service and applicable Medicare requirements.
7.0 Services for Minors
Radiant Health and Wellness may provide appropriate physical therapy services to individuals across the lifespan, including infants, children, and adolescents. When the individual receiving services is a minor, the parent or legal guardian entering into this Agreement represents that they possess the legal authority necessary to consent to services on the minor’s behalf.
The parent or legal guardian agrees to provide accurate and relevant information regarding the minor and to participate in care and decision-making as reasonably necessary.
Radiant Health and Wellness may require a parent or legal guardian to be present or otherwise participate in some or all services depending upon the child’s age, nature of treatment, applicable law, and Dr. Harasim’s professional judgment.
Nothing in this Agreement is intended to alter rights or obligations established by applicable law.
8.0 Confidentiality and Privacy
Radiant Health and Wellness will maintain Client information in accordance with applicable professional, privacy, and healthcare requirements. Information shared privately by the Client in connection with physical therapy services and other protected healthcare information will be handled in accordance with applicable privacy requirements and the Practice’s privacy policies.
Radiant Health and Wellness will not disclose the Client’s information except with appropriate authorization or as permitted or required by applicable law, including circumstances involving treatment, payment, healthcare operations, lawfully issued subpoenas or court orders, reporting requirements, or circumstances involving safety or other legally permitted disclosures. Radiant Health and Wellness will not disclose the Client’s name as a testimonial or reference without the Client’s permission.
9.0 No Transfer of Intellectual Property
Any educational content or materials provided or made available by Radiant Health and Wellness, including but not limited to written documents, videos, audios, handouts, exercises, movement instructions, educational resources, worksheets, or other proprietary materials (“Intellectual Property”), are copyrighted and provided to the Client for personal use only.
The Client is not authorized to reproduce, sell, distribute, publish, modify, create derivative works from, or use Radiant Health and Wellness’s Intellectual Property for commercial purposes without express written permission.
All Intellectual Property remains the property of Radiant Health and Wellness and/or its respective rights holders.
10.0 Termination of the Professional Relationship
The Client may choose to discontinue physical therapy at any time. Discontinuing care does not automatically entitle the Client to a refund for services already provided or for a purchased appointment the Client voluntarily chooses not to use, except where otherwise required by applicable law.
Radiant Health and Wellness may decline to establish or may terminate the professional relationship when Dr. Harasim determines that continued physical therapy is no longer clinically, professionally, or reasonably appropriate.
Reasons may include, but are not limited to:
- The Client requires care outside Dr. Harasim’s scope of practice or services offered;
- Another provider or level of care is more appropriate;
- Continued physical therapy is no longer clinically indicated;
- Continuing the professional relationship is no longer clinically or professionally appropriate;
- The Client repeatedly fails to comply with Practice policies or payment obligations;
- The Client engages in threatening, abusive, harassing, discriminatory, or otherwise inappropriate behavior;
- or Other circumstances make continuation of the professional relationship inappropriate or unsafe.
When clinically appropriate and reasonably possible, Radiant Health and Wellness will provide reasonable notice and/or appropriate recommendations to assist with transition to another provider or resource.
11.0 LIABILITY
EXCEPT AS EXPRESSLY PROVIDED IN THIS AGREEMENT, RADIANT HEALTH AND WELLNESS MAKES NO GUARANTEES, REPRESENTATIONS, OR WARRANTIES OF ANY KIND OR NATURE, EXPRESS OR IMPLIED, WITH RESPECT TO THE PRIVATE PHYSICAL THERAPY SERVICES OR THE SERVICES NEGOTIATED, AGREED UPON, AND RENDERED.
IN NO EVENT SHALL RADIANT HEALTH AND WELLNESS BE LIABLE TO THE CLIENT FOR ANY INDIRECT, CONSEQUENTIAL, OR SPECIAL DAMAGES. NOTWITHSTANDING ANY DAMAGES THAT THE CLIENT MAY INCUR, RADIANT HEALTH AND WELLNESS’S ENTIRE LIABILITY UNDER THIS AGREEMENT, AND THE CLIENT’S EXCLUSIVE REMEDY, SHALL BE LIMITED TO THE AMOUNT ACTUALLY PAID BY THE CLIENT TO RADIANT HEALTH AND WELLNESS UNDER THIS AGREEMENT FOR SERVICES RENDERED THROUGH AND INCLUDING THE TERMINATION DATE.
Nothing in this Agreement is intended to waive or limit any right or liability that cannot lawfully be waived or limited under applicable law.
12.0 INDEMNIFICATION
CLIENT SHALL DEFEND, INDEMNIFY, AND HOLD HARMLESS RADIANT HEALTH AND WELLNESS, ITS OFFICERS, EMPLOYEES, CONTRACTORS, DIRECTORS, RELATED ENTITIES, TRUSTEES, AFFILIATES, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LIABILITIES AND EXPENSES WHATSOEVER — INCLUDING WITHOUT LIMITATION, CLAIMS, DAMAGES, JUDGMENTS, AWARDS, SETTLEMENTS, INVESTIGATIONS, COSTS, ATTORNEYS’ FEES, AND DISBURSEMENTS — WHICH ANY OF THEM MAY INCUR OR BECOME OBLIGATED TO PAY ARISING OUT OF OR RESULTING FROM THE CLIENT’S PARTICIPATION IN, RECEIPT OF, ACCESS TO, OR USE OF THE PRIVATE PHYSICAL THERAPY SERVICES, PRODUCTS, EDUCATIONAL CONTENT, RESOURCES, OR OTHER MATERIALS PROVIDED OR MADE AVAILABLE IN CONNECTION WITH THE SERVICES, EXCLUDING, HOWEVER, ANY SUCH EXPENSES AND LIABILITIES WHICH MAY RESULT FROM A BREACH OF THIS AGREEMENT OR SOLE NEGLIGENCE OR WILLFUL MISCONDUCT BY RADIANT HEALTH AND WELLNESS OR ANY OF ITS SHAREHOLDERS, TRUSTEES, AFFILIATES, OR SUCCESSORS.
CLIENT SHALL DEFEND RADIANT HEALTH AND WELLNESS IN ANY LEGAL ACTIONS, REGULATORY ACTIONS, OR THE LIKE ARISING FROM OR RELATED TO THIS AGREEMENT, THE CLIENT’S PARTICIPATION IN OR RECEIPT OF THE PRIVATE PHYSICAL THERAPY SERVICES, OR THE CLIENT’S USE OF THE SERVICES, PRODUCTS, EDUCATIONAL CONTENT, OR RESOURCES PROVIDED IN CONNECTION WITH THE SERVICES, SUBJECT TO APPLICABLE LAW. CLIENT RECOGNIZES AND AGREES THAT ALL OF RADIANT HEALTH AND WELLNESS’S SHAREHOLDERS, TRUSTEES, AFFILIATES, AND SUCCESSORS SHALL NOT BE HELD PERSONALLY RESPONSIBLE OR LIABLE FOR ACTIONS OR REPRESENTATIONS OF RADIANT HEALTH AND WELLNESS EXCEPT AS OTHERWISE PROVIDED BY APPLICABLE LAW.
IN CONSIDERATION OF AND AS PART OF THE CLIENT’S PAYMENT FOR THE RIGHT TO RECEIVE OR ACCESS THE PRIVATE PHYSICAL THERAPY SERVICES, PRODUCTS, EDUCATIONAL CONTENT, RESOURCES, AND OTHER MATERIALS MADE AVAILABLE IN CONNECTION WITH THE SERVICES, THE CLIENT, AND WHERE LEGALLY APPLICABLE THE CLIENT’S HEIRS, EXECUTORS, ADMINISTRATORS, SUCCESSORS, AND ASSIGNS, RELEASES, WAIVES, ACQUITS, DISCHARGES, INDEMNIFIES, DEFENDS, HOLDS HARMLESS, AND FOREVER DISCHARGES RADIANT HEALTH AND WELLNESS AND ITS SUBSIDIARIES, PRINCIPALS, DIRECTORS, EMPLOYEES, AGENTS, CONTRACTORS, HEIRS, EXECUTORS, ADMINISTRATORS, SUCCESSORS, AND ASSIGNS, AS WELL AS ANY APPLICABLE VENUE WHERE IN-PERSON SERVICES OR ACTIVITIES ARE PROVIDED AND ITS OWNERS, EXECUTIVES, AGENTS, OR STAFF (“RELEASEES”), FROM ACTIONS, CAUSES OF ACTION, CONTRACTS, CLAIMS, SUITS, COSTS, DEMANDS, AND DAMAGES OF WHATEVER NATURE OR KIND IN LAW OR EQUITY ARISING FROM THE CLIENT’S PARTICIPATION IN OR RECEIPT OF THE PRIVATE PHYSICAL THERAPY SERVICES OR THE CLIENT’S RECEIPT OF, ACCESS TO, OR USE OF THE SERVICES, PRODUCTS, EDUCATIONAL CONTENT, RESOURCES, OR OTHER MATERIALS PROVIDED IN CONNECTION WITH THE SERVICES, EXCEPT TO THE EXTENT SUCH RELEASE OR WAIVER IS PROHIBITED BY APPLICABLE LAW.
13.0 Entire Agreement
This Agreement reflects the agreement between Radiant Health and Wellness and the Client concerning the Initial Physical Therapy Evaluation + Treatment and related physical therapy services purchased under this Agreement.
This Agreement, together with applicable purchase terms expressly presented to the Client at checkout, reflects the parties’ understanding with respect to the subject matter covered herein. The Agreement supersedes prior written or oral representations concerning those terms. The Agreement may not be materially amended, altered, or supplemented except in writing as permitted by applicable law.
14.0 Dispute Resolution
If a dispute arises out of this Agreement that cannot be resolved by mutual consent, the Client and Radiant Health and Wellness agree to attempt to mediate the dispute in good faith for up to 30 days after notice of the dispute is given.
The mediation shall be conducted by a mediator mutually agreed upon by both parties. If the parties cannot agree on a mediator, one may be appointed as permitted by applicable law.
If the dispute is not resolved through mediation within the 30-day period, either party may initiate legal proceedings. Any legal action arising out of or relating to this Agreement shall be brought in the courts of Massachusetts, where Radiant Health and Wellness’s principal place of business is located, except where otherwise required by applicable law.
15.0 Severability
If any provision of this Agreement is found to be invalid or unenforceable by a court of competent jurisdiction, such invalidity or unenforceability shall not affect the remaining provisions, which shall continue in full force and effect. The remaining provisions shall be interpreted in a manner that gives effect to the original intent of the parties as closely as legally permissible.
16.0 Waiver
The failure of either party to enforce any provision of this Agreement shall not be construed as a waiver or limitation of that party’s right to subsequently enforce that provision or any other provision.
17.0 Applicable Law
This Agreement shall be governed and construed in accordance with the laws of the Commonwealth of Massachusetts, without giving effect to conflicts-of-law provisions, except to the extent that mandatory laws or professional requirements applicable to physical therapy services provided in Connecticut or another applicable jurisdiction apply.
18.0 Binding Effect
This Agreement shall be binding upon the parties and their respective successors, permissible assigns, heirs, executors, and administrators.
19.0 Headings
The headings used in this Agreement are for reference and organizational purposes only and shall not affect the meaning or interpretation of any provision.
I voluntarily choose to receive physical therapy services from Radiant Health and Wellness and Dr. Beata Harasim, PT, DPT, FAAOMPT.
I understand that my physical therapy services will be individualized based upon my history, presentation, evaluation findings, goals, response to care, safety considerations, professional scope, and Dr. Harasim’s clinical judgment.
1. Description of Physical Therapy Services and Risks
Physical therapy services may include, but are not limited to, physical and movement assessment, musculoskeletal and neuromuscular assessment, prescribed movement, therapeutic activities, neuromuscular re-education, movement and mobility interventions, manual therapy, joint mobilization or manipulation when appropriate, soft-tissue and myofascial techniques, functional retraining, education, and other appropriate physical therapy interventions.
I understand that physical therapy and hands-on interventions may involve risks or temporary responses, which may include soreness, stiffness, discomfort, fatigue, bruising or skin irritation, numbness, tingling, temporary changes or increases in symptoms, dizziness or lightheadedness, or other unexpected responses or injuries.
I accept the risks reasonably associated with my voluntary participation in physical therapy.
I agree to communicate relevant symptoms, medical conditions, precautions, restrictions, reactions, changes in health status, and concerns to Dr. Harasim.
I understand that I have the right to ask questions about any proposed physical therapy intervention.
I have the right to accept or refuse any proposed treatment, request that an intervention be modified, or ask that hands-on treatment be stopped at any time. Consent to physical therapy does not require me to consent to every technique or intervention that may be offered.
2. Manual Therapy and Manipulation
I understand that manual therapy may include a range of hands-on techniques selected according to my evaluation findings and clinical presentation.
When clinically appropriate, these techniques may include joint mobilization, soft-tissue techniques, myofascial techniques, muscle energy techniques, and joint manipulation.
Dr. Harasim will determine whether a particular technique is appropriate based upon clinical findings, precautions, contraindications, professional judgment, and my consent. I understand that I may ask questions about a proposed manual intervention and may decline or stop any technique at any time.
3. Optional MiHealth Bioenergetic Support
I understand that MiHealth may be offered during eligible in-person appointments as an optional bioenergetic wellness tool. I understand that MiHealth is not represented as a medical diagnostic tool or medical treatment and is not represented as physical therapy merely because it may be used during an appointment that also includes physical therapy services.
I understand that use of MiHealth is optional and that I may decline or discontinue it at any time without affecting my ability to receive physical therapy services.
4. Possible Benefits
Potential benefits of physical therapy may include improvement in areas such as pain, strength, mobility, movement, balance, coordination, physical function, activity tolerance, performance, and ability to participate in desired activities.
I understand that individual responses vary and no particular benefit or outcome can be guaranteed.
5. Alternatives and Participant Rights
I understand that I may ask questions regarding my evaluation, treatment options, recommendations, potential benefits, risks, and alternatives.
Depending upon my individual circumstances, alternatives may include declining a proposed intervention, receiving a different physical therapy intervention, seeking care from another physical therapist or healthcare professional, pursuing medical evaluation, or choosing not to receive treatment.
I understand that I may withdraw consent to a particular physical therapy intervention at any time.
6. Medical Care and Medical Clearance
I understand that physical therapy does not replace medical evaluation or treatment when such care is appropriate.
I am responsible for seeking appropriate medical evaluation and treatment when necessary and for communicating relevant health information that may affect my participation.
I understand that I should consult with an appropriate licensed healthcare provider when necessary before beginning healthcare, exercise, or physical activity for which medical clearance may be appropriate.
I confirm that I am voluntarily participating and agree to communicate known medical conditions, restrictions, precautions, or changes relevant to my care.
7. Payment and Participation
I understand that my Initial Physical Therapy Evaluation + Treatment is contingent upon payment of the fee displayed and accepted at the time of purchase.
I understand that I have ninety (90) days from the date of purchase to use the Initial Evaluation + Treatment unless otherwise expressly stated at the time of purchase or required by applicable law.
I understand that purchasing the Initial Evaluation + Treatment does not commit me to additional visits or a course of physical therapy.
I acknowledge that participation does not guarantee any particular outcome.
8. Liability Release
I acknowledge and voluntarily assume the risks reasonably associated with my participation in physical therapy and the services provided.
To the fullest extent permitted by applicable law, I release and hold harmless Radiant Health and Wellness, PLLC, its employees, contractors, agents, associated service providers, and applicable facilities or venues from claims arising from risks inherent in or reasonably associated with my voluntary participation, except to the extent resulting from professional negligence, malpractice, willful misconduct, or other liability that cannot lawfully be waived.
By submitting payment, I acknowledge that I have read and understand this Informed Consent, Waiver & Release of Liability and agree to its terms.
We may use or disclose healthcare information for purposes of treatment, payment, healthcare operations, and other purposes permitted or required by applicable law. We may disclose health information to other healthcare professionals involved in your care when permitted by law. We may disclose health information to notify or assist in notifying a family member or another person responsible for your care regarding your medical condition or in an emergency when permitted by applicable law. We may disclose health information when required or permitted for governmental, public-health, legal, regulatory, law-enforcement, national-security, workers’ compensation, or other legally authorized purposes.
We may leave messages or communicate through telephone, voicemail, email, text, or other approved communication methods for purposes such as scheduling appointments and administering services, consistent with applicable privacy requirements and your communication preferences where required.
You may have rights under applicable law including the right to:
- Request restrictions on certain uses and disclosures of your health information, although Radiant Health and Wellness may not be required to agree to all requested restrictions;
- Request that your health information be communicated to you in an alternative manner or at an alternative location;
- Inspect and obtain copies of health information as provided by applicable law;
- Request amendment of health information, although Radiant Health and Wellness may not be required to agree to the requested amendment;
- and Receive an accounting of certain disclosures of your health information as provided by applicable law.
Radiant Health and Wellness is required to maintain the privacy of protected health information in accordance with applicable law.
Questions or complaints regarding privacy rights may be directed to:
Dr. Beata Harasim
860-266-7745
Beata@HolisticDrBeata.com
Formal complaints may also be submitted to the U.S. Department of Health and Human Services, Office for Civil Rights, as applicable.
By agreeing to these Terms, I acknowledge receipt of this privacy information and authorize and consent to the use and disclosure of my health information as described above and as otherwise permitted or required by applicable law.
Client Acknowledgment
By submitting payment for the Initial Physical Therapy Evaluation + Treatment, I acknowledge and agree that:
- I have read and understand these Terms & Conditions and Informed Consent.
- I understand that my purchase includes one 60-minute Initial Physical Therapy Evaluation + Treatment.
- I understand that I have ninety (90) days from the date of purchase to use the appointment unless otherwise expressly stated or required by applicable law.
- I understand that the fee I am responsible for is the fee displayed and accepted at checkout at the time of my purchase.
- I understand that purchasing the initial appointment does not commit me to additional physical therapy visits.
- I understand that additional physical therapy, if recommended and elected, is purchased separately.
- I understand that my care will be individualized and that no particular technique or intervention is guaranteed or required.
- I understand that physical therapy may include hands-on treatment, manual therapy, neuromuscular re-education, prescribed movement, functional retraining, education, and other appropriate physical therapy interventions.
- I understand that I may ask questions about, decline, modify, or stop any proposed physical therapy intervention.
- I understand that MiHealth, if offered, is optional, is provided as a bioenergetic wellness tool, and is not represented as medical diagnosis or medical treatment.
- I understand that this physical therapy purchase does not include functional laboratory testing or review, nutrition or gut-health consultation, holistic health coaching, or somatic, emotional, or energetic coaching.
- I understand that Radiant Health and Wellness does not bill insurance directly; I am responsible for verifying my insurance and HSA/FSA benefits and requirements, obtaining any required referrals, prescriptions, authorizations, or other documentation, submitting any superbill provided to me, and communicating directly with my insurance carrier or HSA/FSA administrator regarding reimbursement or eligibility. I understand that reimbursement and HSA/FSA eligibility are not guaranteed and that I remain responsible for the full fee charged regardless of reimbursement.
- I understand that insurance reimbursement and HSA/FSA eligibility are not guaranteed and that I remain responsible for the fee charged regardless of reimbursement.
- I understand that no particular health or physical therapy outcome has been promised or guaranteed.
- I understand that these physical therapy services do not replace emergency or other medical care when such care is appropriate.
- I have had the opportunity to ask questions before purchasing.
- I voluntarily consent to physical therapy services under these terms.
By submitting payment, I acknowledge that I have read, understand, and agree to the Terms & Conditions and Informed Consent for Private Physical Therapy Services.
Please email any questions to Dr. Beata at Beata@HolisticDrBeata.com.
Please e-mail any questions to Dr. Beata at Beata@HolisticDrBeata.com