Media Agreement Form
I grant permission to Polygon HQ to use my image (photographs and/or videos) for use in media publications including but not limited to: Videos, Newsletters, Brochures, General Publications, Website, Social Media Accounts, etc.
I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used with them now or in the future whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image.
Credit Card on File Agreement
Polygon HQ Physical Therapy has implemented a credit card on file policy. Much like many other businesses such as a hotel or car rental agency, attorneys, etc. we now have a similar policy where we ask for a credit card which may be used later to pay any balance that may be due on your bill.
Co-pays are still due at the time of service.
At check in, your credit card information will be obtained and kept securely until your insurance(s) have paid their portion and notifies us of the balance due, if any. At that time, you will be sent a statement which you will have 30 days to pay or set up a payment plan with us. After 30 days, if the bill remains unpaid or unaddressed, we will bill your credit card.
Your ability to dispute a charge or question your insurance company's determination of payment will remain unchanged.
If you have any questions about our policy, please do not hesitate to ask.
By acknowledging here, I authorize Polygon HQ Physical Therapy to keep my signature and my credit card information securely on-file in my account.
If the credit card that I give today changes, expires, or is denied for any reason, I agree to immediately give Polygon HQ Physical Therapy a new, valid credit card which I will allow them to charge over the telephone. Even though Polygon HQ Physical Therapy is not processing the new card in person, I agree that the new card may be used with the same authorization as the original card I presented.