CHAMPION PT AND PERFORMANCE
Client Policy Terms and Agreements
Consent for Care and Policy Disclosure: I do hereby give my consent for Champion PT and Performance, Inc. to furnish fitness, medical care and/or treatment considered in the assessment, evaluation and treatment of my physical condition(s) as described to me or as my physician, therapist and/or fitness instructor determines are necessary. Champion PT & Performance, Inc. is an out of network physical therapy provider. You are responsible for payment in full at the time of service. You may request an invoice of your charges to submit for reimbursement. We are not responsible for this process and any reimbursement you may obtain. We require a 24-hour notice for cancellation of any appointments. Any cancellations or no shows with less than 24-hours notice are subject to a fee equivalent to the cost of your scheduled appointment. There is a $50 fee for copies of your medical records. A $25 fee will be charged for any checks returned for insufficient funds, plus any bank fees incurred.
Assignment of Benefits/Release of Information: I certify that all information on these forms are correct. I hereby assign all medical benefits to which I am entitled, to include any major medical, private insurance and third-party payers to Champion PT and Performance, Inc. A photocopy of this assignment is to be considered as valid as the original. I hereby authorize Champion PT and Performance Inc. to release all information necessary, including medical records to secure payment. I understand that I am financially responsible for all charges not covered by my insurance or other third-party payers and that the balance after insurance or third party payment has been made is due within thirty (30) days.
Notice of Privacy: I have received and reviewed this facility’s Notice of Privacy Practices, which explains how my private health information will be used and disclosed. I understand that I am entitled to receive a copy of this document and may refuse to sign this acknowledgment form. By signing this form, I consent to the use and disclosure of my protected health information for the purpose of treatment, payment and healthcare operations. I have the right to revoke this consent, in writing, except where disclosures have already been made in reliance on my prior consent.
Consent and Release for Use and Disclosure of Image, Voice, and/or Written Testimonials: I, hereby consent to the photographing, recording and unlimited use of my likeness (including my name, voice and/or image) for commercial, promotional or other use, in any medium, by Champion PT & Performance, Inc. and its employees, affiliates, subsidiaries, licensees, successors, and assigns. I waive all rights of attribution, inspection, or approval for any use of my likeness. Champion PT & Performance Inc. and its employees, affiliates, subsidiaries, licensees, successors, and assigns are held expressly harmless for any liability, legal and/or financial, incurred as a result of said use. I waive any right to royalties or other compensation arising from or related to the use of my likeness. All right, title, and interest to any photographs, recordings, and any other materials using my likeness shall be the sole property of Champion PT & Performance Inc. I shall have no interest in any such materials nor shall I have any right to use the name or trademarks of Champion PT & Performance Inc. without its express, written permission. We consider our center to be a center of excellence and occasionally take photographs, videos, and other forms of media of our facility and/or services for educational and promotional use. This may include, but is not limited to, book publications, journal article publications, use on our websites, and social media accounts.
I provide my authorization knowing that The Protected Health Information that is used or disclosed pursuant to this authorization, including Protected Health Information contained in any photographs, videotapes, or interviews, may be subject to re-disclosure by the recipient(s) and may no longer be protected by HIPAA or other state or federal laws.
I, authorize Champion PT & Performance Inc. and its employees, agents, and authorized representatives, to use and/or disclose my Protected Health Information contained in any photographs, videos, medical and physical therapy records, and/or audio recordings for the following purposes: Use in internal and external advertising, marketing, public relations or collateral materials, including but not limited to posting on Champion PT & Performance’s website and social media sites, use in news releases or stories, including television, newspaper, or radio broadcasts, use in internal and external education and/or training programs for the public and/or medical professionals, including but not limited to use on public websites and social media sites.
I hereby acknowledge that Champion PT & Performance Inc. or any of its agents or employees have not made any representations or warranties of any kind with respect to any medical or other advice or information that I may receive in connection with my appearance and that I have not relied on any such representations or warranties in agreeing to participate in the recording of my voice and/or likeness as described above or in the execution of this consent for use and disclosure of image, voice and/or written testimonials (the “consent”).
I am signing this Consent and Release voluntarily, having read it in its entirety and understanding the contents thereof to my satisfaction, and I acknowledge that it is binding upon me, my legal representatives, heirs and assigns. I understand that this Consent will be signed contemporaneously with the form entitled Authorization for Use and Disclosure of Protected Health Information for Marketing and Promotional Purposes (the “Authorization”), and I agree that in the event of a conflict between the two documents, the terms of the Authorization shall govern.
The parties agree to be bound by the terms of this agreement in consideration for the mutual promises and benefits to be revived by them, the adequacy and sufficiency of which they acknowledge.
Program Services: The services being requested are fitness programs. Champion Physical Therapy and Performance, Inc. will make every attempt to provide the best service possible, acknowledging client requests (such as trainer gender, age, appointment time, etc.) but will not be held liable, or otherwise does not affect the terms of this agreement, in the event these requests cannot be met. Champion Physical Therapy and Performance, Inc. must not delay performance of services in excess of six months from the date the agreement is entered into.
Monthly Session Use and Auto Renewal Agreement: Fitness clients are starting a monthly membership, which auto renews on the same calendar date as the original contract date each month for the duration of the contract. Unused sessions do not carry over and expire at the end of each month. Sessions are not transferable to another package. Membership will automatically renew for the same contract duration. I understand that unless I submit a written notice of cancellation within 7 days of the agreement expiration date, this contract will automatically renew using my credit card on file with the same terms and duration as the original agreement.
Sports Performance Membership will not automatically renew. I understand that my membership expires after the purchased amount of sessions is used, at the end of a quarterly session, or 6 weeks after the original agreement date, whichever comes first. Sessions do not carry over and any remaining sessions are considered to have lapsed and will immediately discontinue. After sessions expire, I understand that I will need to purchase another program, which will carry these same contract terms.
Professional athletes with a Semi-Private Sports Performance Membership are paying a monthly membership fee. Membership will not automatically renew. I understand that my membership expires after the purchased amount of sessions is used or 4 weeks after the original agreement date, whichever comes first. Sessions do not carry over and any remaining sessions are considered to have lapsed and will immediately discontinue. After sessions expire, I understand that I will need to purchase another program, which will carry these same contract terms.
Failure to use the services does not relieve the Buyer or the Client of their obligations, (regardless of circumstances), to pay fees, late charges and other monies due under this Agreement in full. The completion date will be extended when a signed doctor’s note is received stating a medical reason, which prevents a fitness training session program to be completed within the normal allotted time period.
Appointment Cancellation and No-Show Policy: We require a 24-hour notice for cancellation of any appointments. Any cancellations or no shows with less than 24-hours notice are subject to a fee equivalent to the cost of your scheduled appointment of the loss of that session.
Late Payment: If your payment is more than ten (10) days late, you will be charged a late charge of twenty dollars ($20.00) per payment.
Check Return Fee: A twenty five dollar ($25) fee will be charged for any checks returned for insufficient funds, plus any bank fees incurred.
Prepayment and Payment in Full: There is no prepayment charge applicable to this agreement. If a client desires to pay in full for future services, the client’s execution of this agreement hereby constitutes a written request to make such payment in full. All paid-in-full memberships are non-refundable.
Changing Membership: The buyer will be allowed to change their membership to a higher level of service with the signing of a new membership agreement each time a change is made. Changing to a lower level of service is not allowed during the terms of your agreement.
Suspension of Membership: A membership may be suspended with written notice ten (10) days prior to the next scheduled payment date. Suspensions must be for a minimum of three (3) weeks and a maximum of six (6) months. The suspension must have an end date when being scheduled. No open-ended suspensions are permissible with the exception of a signed medical release. You may be charged a thirty dollar ($30) per month holding fee to retain your spot in our programs for each suspension. Only one (1) suspension is allowed per term of agreement.
Cancelation of Agreement: You may cancel this agreement any time before midnight of the third business day after the date of this agreement. After that time, all agreements are binding for the full initial term of the contract and may only be canceled under doctor’s orders complete with a signed notice or for any of the circumstances listed in the below section “Buyer’s Rights.”
Refunds: No refunds shall be made for services purchased, except as specifically provided in this Agreement.
Buyer’s Rights: Massachusetts State Law requires that we the seller of this contract must:
- Refund you, the Buyer, at least 90% of the pro rated cost of any unused services, within 30 days after the request if:
- The buyer is unable to receive benefits from the seller’s services by reason of death of disability; or
- The buyer relocates more than eight (8) miles from his present location and more than thirty (30) miles from the seller’s facility and any substantially similar facility that will accept the sellers obligation under the agreement and this Article: or
- The seller relocates his facility more than eight (8) miles from its present location or the services provided by the seller are materially impaired.
Buyer’s Default: Buyer and Client shall be deemed in default of this Agreement upon the failure to comply payment as and when due. Upon default, Champion Physical Therapy and Performance, Inc. shall have the rights and remedies available, including termination of this Agreement and institution of an action for all applicable damages. If Champion Physical Therapy and Performance, Inc. delays or refrains from exercising any rights under this with any of the terms and conditions of the Agreement, including, but not limited to, the obligation to make any agreement, Champion Physical Therapy and Performance, Inc. does not waive the right to receive full and timely payments and other charges due under this agreement.
Permission to Use Your Image: We consider our center to be a center of excellence and occasionally take photographs, videos, and other forms of media of our facility and/or services for educational and promotional use. This may include, but is not limited to, book publications, journal article publications, use on our websites, and social media accounts. By signing below, you are agreeing to allow us the use of your name and likeness, voice, verbal statements, and image in any of these mediums and uses without compensation.
Security Cameras: This facility uses video recordings in public spaces for security purposes only. The video will be erased periodically and is not utilized without the concern for the patient and or the guardian of the patient. Your signature below indicates that you understand the purpose of these recordings in the manner in which they are used by Champion Physical Therapy and Performance, Inc. (Security Purposes only).
Successors and Assigns: Buyer and Client agree that all terms and conditions of the Agreement shall be binding upon the heirs, Personal Representatives, lawful successors, and assigns of Buyer and Athlete, and anyone claiming by or through Buyer or Athlete.
Enforceability: The parties agree that if any provision or portion of this Agreement is declared void and unenforceable, such provisions or portion of a provision shall be deemed severed from this Agreement, which shall otherwise remain in full force and effect. Further, if any such provision or portion of a provision may be reduced and/or narrowed in scope or the like, such provision or portion of a provision shall be reduced, narrowed and/or the like, and so enforced. However, Buyer and Client specifically agree all the terms and conditions are to be enforced and Buyer and Client specifically waive any statute or other right of any type, which would invalidate the enforceability of any provision or portion of a provision of this Agreement.
Governing Law: This Agreement shall be governed and enforced in accordance with the laws of the State of Massachusetts. In the event litigation is necessary to enforce any of the terms and conditions of this Agreement, Champion Physical Therapy and Performance, Inc., Buyer, and Client agree that the venue for such court action shall exclusively be in Middlesex County, Massachusetts.
Attorney Fees: In any action at law or equity that is brought to enforce the terms of this agreement or dispute thereof, each party shall be responsible for its own attorney’s fees and cost and an award of such fees and costs shall not be grated in contradiction to this provision. This provision shall be construed as applicable to this entire agreement and any amendments created and properly executed hereunder.
Mediation and Arbitration: The parties agree that should a dispute arise between them they will first submit the matter to mediation. In the event the parties cannot agree to a resolution in mediation then they agree to submit the matter to binding Arbitration to be held in Waltham, MA. If they are unable to resolve the dispute in mediation then the parties shall submit the dispute for final determination to the commercial division of the American Arbitration Association or they may by mutual consent agree to an alternative method of dispute resolution. The parties agree that rights and responsibilities under this agreement are individual in nature and they will not attempt to be a part of or join in any class related to this license agreement.
Notice: All notices to Champion Physical Therapy and Performance, Inc. shall be mailed (certified or registered with return receipt required) to Champion Physical Therapy and Performance, Inc., 110 Clematis Ave., Waltham, MA 02453.
By signing this Agreement, Buyer acknowledges that Buyer has read, understood and agreed with all terms and conditions of this agreement located on the front and reverse side of the Agreement. This agreement constitutes the entire agreement of the parties and no other agreement or understanding exists between Buyer and Champion Physical Therapy and Performance, Inc. Champion Physical Therapy and Performance, Inc. has made no express or implied warranties or misrepresentations other than those expressly set forth in this Agreement to induce Buyer to enter into this Agreement. Any conflict between the original Agreement and any copy of the original Agreement shall be controlled by the original Agreement.
In agreeing to utilize fitness and/or physical therapy services provided by Champion Physical Therapy and Performance, Inc. (“Champion”) and to use the facilities located at 110 Clematis Ave Suite 2 Waltham, MA 02453, I agree as follows:
I fully understand and acknowledge that (a) the activities in which I will engage as part of the services provided by Champion and the activities and equipment I may use as a part of that service have inherent risks, dangers, and hazards and such exists and my participation in these activities; (b) in such activities and/or use of such services may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that, could cause serious disability; (c) these risks and dangers may be caused by the negligence of the representatives or employees of Champion, the negligence of the participants, the negligence of others, accidents, breaches of contract, or other causes.
By my participation in these activities and for use of these services, I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or the conduct of the representatives or employees of Champion, or by any other person. I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify Champion Physical Therapy and Performance, Inc. and their representatives, employees, and assigns from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of any services or participation in these activities.
I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the representatives or employees of Champion Physical Therapy and Performance, Inc.
Buyer and client, on behalf of client, his/her heirs, assigns next of kin, agrees to fully release Champion Physical Therapy and Performance, Inc (as well as any of its owners, employees or other authorized agents, including independent contractors) from any and all liability, claims and/or litigation resulting from any and all services and the physical activities, even if caused by the negligence, gross negligence, intentional acts or omissions and/or any other type of fault of Champion Physical Therapy and Performance, Inc, its owners, employees, or other authorized agents, including independent contractors.
Disease Transmission Release: Participation includes possible exposure to and illness from infectious diseases including but not limited to MRSA, influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist. I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately. By visiting Champion, I voluntarily assume all risks related to exposure to such diseases, such as COVID-19, influenza, MRSA and many others.
You acknowledge that you have carefully read this waiver and release and fully understand that it is a release of liability. You expressly agree to release and discharge Champion Physical Therapy and Performance, Inc and all affiliates, employees, agents, representatives, successors, or assigns, from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring legal action against Champion Physical Therapy and Performance, Inc for negligence, personal injury or property damage.
Note: Should any part of this agreement be found by a court of law to be against public policy or in violation of any state statute or case precedence, then the remainder of this document will remain in full force.
*** Updated 4/28/2022
