Hooper’s Beta Physical Therapy:
Master Service Agreement
This Master Service Agreement ("Agreement") is entered into by and between Jason Hooper Physical Therapy, P.C. ("Provider") and the undersigned client ("Client", "I", or "you").
1 | Consent to Service & Scope
I, %CONTACT_NAME%, voluntarily elect to receive:
In-person Physical Therapy (PT): Only while physically present in California, provided by Jason Hooper, PT, DPT, OCS, SCS.
Remote Health-Coaching: Non-medical education and wellness advice for clients outside California. This does not include medical diagnosis or hands-on treatment.
2 | Telehealth & Jurisdictional Scope
I consent to remote services via secure video/audio technologies. I agree that the location-based scope defined in Section 1 applies equally to telehealth: remote sessions conducted while I am physically within California are Physical Therapy, and sessions conducted while I am outside California are Health-Coaching.
3 | AI Digital Assistant & Session Recording
To ensure the Provider can focus entirely on my care rather than typing notes, a HIPAA-compliant AI healthcare assistant is used to record and summarize all sessions. These summaries are used strictly for clinical charting and coaching documentation and are reviewed by the Provider.
4 | Health Statement & Participant Duties
I affirm my intake information is accurate. I will immediately stop any activity causing unusual pain or distress and inform the Provider. I am responsible for maintaining a safe exercise environment and have access to emergency services (911).
5 | Informed Consent & Risks
Interventions: May include manual therapy (CA only), therapeutic exercise, and movement education.
Risks: I recognize that exercise carries inherent risks, including muscle strain, soreness, fainting, cardiac events, or, in rare cases, serious injury or death. I voluntarily assume these risks.
Results: No specific results or "cures" are guaranteed.
6 | Liability Release & Indemnification
I release and hold harmless Jason Hooper Physical Therapy, P.C. from any liability for injury or loss arising from my participation, except for losses caused by gross negligence or willful misconduct. I agree to indemnify and defend the Provider against any third-party claims related to my participation.
7 | Facility & Professional Disclaimers
The Wall Climbing Gym: I acknowledge the Provider is an independent practitioner, not an agent of the Gym.
Nutrition: Discussions are for general educational information regarding nutrition and supplements only; the Provider is not a licensed dietitian and is not providing medical nutrition therapy to treat specific conditions.
8 | Intellectual Property (IP)
All exercise programs, videos, and PDFs provided are the property of Jason Hooper Physical Therapy, P.C. and are for my personal, non-commercial use only. Copying, sharing, or distributing these materials is strictly prohibited.
9 | Governing Law
This agreement is governed by California law. Any disputes shall be resolved in San Diego County, CA.
10 | Cancellation & Refund Policy
Because appointment times are reserved exclusively for you and last-minute changes prevent other clients from receiving care, the following tiered refund schedule applies to all cancellations and client-initiated rescheduling based on the session's scheduled start time:
72+ Hours Notice: 100% Refund (or full credit applied to reschedule)
48 – 72 Hours Notice: 75% Refund
24 – 48 Hours Notice: 50% Refund
Less than 24 Hours Notice: 25% Refund
No-Show: Non-Refundable
Notice Method & Timestamps: Cancellations and rescheduling requests must be submitted directly through the online booking portal or via written email to pt@hoopersbeta.com. The time of the cancellation is determined strictly by the system timestamp.
No-Show Definition: If you fail to arrive for an in-person session or do not join the telehealth video link within the first third (33%) of your scheduled appointment duration, the appointment is deemed forfeited and treated as a non-refundable No-Show.
Discretionary Exceptions: True emergencies (e.g., acute hospitalization, severe family crisis) will be considered on a case-by-case basis at the Provider’s sole discretion.
11 | Privacy & HIPAA Acknowledgement
This section describes how medical information about you may be used and disclosed by Hooper's Beta Physical Therapy and how you can get access to this information. Please review it carefully.
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting us directly at:
You can file a complaint with the U.S. Department of Health and Human Services Office Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, or by calling , calling 1-877-696-6775.
We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
Marketing purposes
Sale of your information
Most sharing of psychotherapy notes
In the case of fundraising:
We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Treat you
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.
Help with public health and safety issues
We can share health information about you for certain situations such as:
Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
This Notice is effective as of the date that this document is signed.