Welcome to Pure - Performance Physical Therapy ("we," "us," or "our"). Your privacy is very important to us, and this Privacy Policy explains how we collect, use, disclose, and safeguard your information when you visit our website or engage with our services. Please read this policy carefully to understand our views and practices regarding your personal data and how we will treat it.
Pure Performance is a fee-for-service/out of network provider. This means that payment is due at the time services are rendered and we will not bill your insurance company.
We can, upon request, provide receipts (superbills) with diagnosis and treatment codes which you may choose to submit to your insurance company.
As such, Pure Performance, PLLC does not provide coordinated care with your insurance company.
We accept cash (exact amount), debit cards, and credit cards. This includes HSA debit cards.
Initial evaluations and one hour treatment sessions are $150.00.
Thirty-minute treatment sessions are available for $80.00 after initial evaluation is performed.
All initial (first time) patients or patients returning to Pure Performance, PLLC with a NEW CONDITION will be required to attend one hour session to allow treating provider time to fully assess current/new condition.
Your appointment time is reserved just for you. To serve you better, we request a minimum of 24 hours notice for any cancellations or changes to your FOLLOW UP appointments.
Patients who provide less than 24 hours notice for a follow up appointment, or NO-SHOW their appointment, will be charged a cancellation/no show fee of $50.
Please make every effort to be on time for all your appointments. Unfortunately, even when one patient arrives late, it can throw off the entire schedule for that day. In addition, rushing or “squeezing in” an appointment shortchanges the patient and contributes to decreased quality of care. Considering this, at the discretion of the treating therapist, patients arriving more than 15 minutes late may be asked to reschedule to another day. Late arrival to the appointment will be considered a no-show, and a $50 fee will be charged to you.
I authorize Pure Performance and its associated professionals to collect and publish photos and/or videos of my treatment. These photos/videos would be usedfor promotional and informational marketing material.
By submitting your intake information you consent to the evaluation and treatment of my condition by Zackary Fedorka DPT, FAAOMPT, CSCS, Cert DN, licensed physical therapist TN #11499.
The physical therapist will explain the nature and purposes of these procedures, evaluation, and course of treatment. The therapist provides a wide range of services, and I understand that I will receive information at the initial visit concerning the evaluation, treatment and options available for my condition.
I acknowledge and understand that I am seeking direct access services or have been referred by my medical provider for evaluation and treatment of my current condition. It is the patient’s responsibility to inform Pure Performance, PLLC, of all the patient’s medical conditions, treatments, and medications at their initial evaluation.
My signature on this form indicates that I have read and understand each of the above patient policies of Pure Performance, PLLC.
I have addressed any concerns I have regarding these policies with Pure Performance, PLLC.
I further understand that by not signing this form I may be refused treatment, as they are essential to the functioning of Pure Performance, PLLC
