You are financially responsible for payment of all services at the time of visit. A minimum of 24 hours advance notice of cancellation of all appointments is required otherwise you will be charged for all or part of the missed appointment. To ensure that the credit card provided is valid, by eSigning this agreement, along with the terms and conditions, you will be test charged a nonrefundable $1 on the credit card you put on file for each appointment booked. In order to cancel any appointment (s) scheduled through, you must call the clinic at 203-625-9608 more than 24 hours in advance of your scheduled appointment time. Peak Wellness does not participate in Medicare or any insurance plans. We have “opted-out” of Medicare, we accept no assignment, and process no medical insurance. Patients are given an original receipt, which can be submitted by the patient to their carrier(s), but we accept no responsibility whatsoever for the extent of reimbursement by that carrier(s). The carrier(s) may then reimburse the patient directly, in whole, in part, or not at all, according to the carrier(s) provisions. If you are a patient with Medicare (Medicare beneficiary), you should be aware that you are giving up all payment by Medicare for services furnished by this “opt-out” practice and should not expect any reimbursement from Medicare for our services. You are also agreeing not to bill Medicare or ask us to bill Medicare for you. You, the patient, are liable for all of the charges, without any Medicare balance billing limits and that Medigap or any other supplemental insurance will not pay toward the services. You are entering into this contract with the knowledge that you have the right to obtain Medicare-covered items and services from physicians who have not opted out of Medicare and you are compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians who have not opted out. Expected or known expiration date of Medicare opt-out period: 4/2/16. In order to facilitate the payment process, we accept major credit cards. If a health professional has referred you, they may be asked to follow your care and guide our practitioner(s) here at the center. This continuity of care can be essential in assuring that you receive the best care intended by your referring health professional. As such, they may be compensated for their time. You have the right to privacy to the fullest extent. Except in the case of extenuating circumstance, personal patient information will be kept confidential. We will not electronically transmit personal patient information, nor are we a healthcare clearinghouse or health plan. In addition to traditional medical and integrative health care services, physical therapy and rehabilitation services, naturopathy, fitness evaluations, exercise physiology, research, nutritional counseling, massage therapy and/or skin care services may on rare occasion result in accident or injury. You assume the risks connected with participation in any and all modalities and services offered by us. Beyond the reason you are requesting care, you represent that you are otherwise in good health and suffer from no physical impairment which would limit the use of the modalities, facilities and/or services you are requesting from us. Furthermore, you agree that Peak Wellness, its practitioners, officers, employees and agents shall not be liable for any claim, demand, or cause of action of any kind whatsoever for, or on account of death, personal injury, property damage or loss of any kind resulting from or related to his/her use of the modalities, facilities and/or services at Peak Wellness. Finally, you are authorizing us to obtain any relevant medical and health information from other practitioners and/or hospitals necessary for your proper treatment and care. Your signature below indicates that you understand, agree, and accept the terms indicated.