I hereby assign and authorize payments directly to Authentic Hand Therapy, LLC of any benefits or series of benefits due because of liability of a third party, or proceeds of such claims resulting from the liability of a third party or organization. I further agree that this assignment will not be withdrawn or voided at any time until all accounts are paid in full. I am not responsible for charges billed above contracted fee schedule for which this facility is contracted. I understand I am financially responsible for all charges not covered by my insurance secondary to waivers or termination of my policy.

Release of Medical Information: I authorize Authentic Hand Therapy, LLC or any professional rendering care of treatment to release medical and supporting documentation of same as complied in the medical records for purposes of benefit payment. (Also see section 6, Acknowledgement of HIPAA Privacy Notice).

Medicare Patient Certification: I certify that this information given by me in applying for payment under Title XVII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original and request.
Disclosure of Health Information: I understand that as part of my health care, Authentic Hand Therapy, LLC originates and maintains paper or electronic records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment.
I understand that a copy of Notice of Private Practices is available upon request which provides a more comprehensive description of information use and disclosures. I understand my rights and privileges and that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.520 of the Code of Federal Regulations.
I understand that as part of this organization’s treatment, payment or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax or secure email.

BY ENTERING MY NAME AND CHECKING THE BOX BELOW I AGREE TO ACCEPT THE TERMS OF THIS CONSENT.

As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. PLEASE REVIEW THIS DOCUMENT CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACY
Authentic Hand Therapy, LLC is dedicated to maintaining the privacy of individually identifiable health information as protected by law, including the Health Insurance Portability and Accountability Act (HIPPA). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. This information is referred to as protected health information or PHI. We are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our organization concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.
This notice contains the following required information:
• How we may use and disclose your PHI
• Your privacy rights in your PHI
• Our obligations concerning the use and disclosure of your PHI

The terms of this notice apply to all records containing your PHI that are created or retained by our organization. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our organization has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our organization will post a copy of our current Privacy Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

B. WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION (PHI) IN THE FOLLOWING WAYS:
The following categories describe the different ways in which we may use and disclose your PHI.

1. Treatment. Our organization may use your PHI to treat you. For example, we may ask you to have evaluations and we may use the results to help us develop an individual plan for services. Many of the people who work for our organization including, but not limited to, our therapists, educators, case managers, doctors, and nurses may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may also disclose your PHI to your primary care physician or other outside health care providers for purposes related to your treatment. Finally, we may disclose your PHI to family members or others who may assist in your care.
2. Payment. Our organization may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer, including Medicaid, to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to Medicaid and other payers or providers to coordinate and assist their billing efforts.
3. Health Care Operations. Our organization may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our organization may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our organization. We may disclose your PHI to other health care providers and entities to assist in their health care operations.
4. Appointment Reminders. Our organization may use and disclose your PHI to contact you and remind you of an appointment.
5. Treatment Options. Our organization may use and disclose your PHI to inform you of potential treatment options or alternatives.
6. Health-Related Benefits and Services. Our organization may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.
7. Release of Information to Family/Friends. Our organization may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a caregiver take an individual to the doctor's office for examination for seizures that occurred while at our organization. We may give the caregiver a copy of a case note for the physician documenting the seizure(s). In this example, the caregiver may have access to this individual's medical information.
8. Disclosures Required By Law. Our organization will use and disclose your PHI when we are required to do so by federal, state or local law.

C. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories describe unique scenarios in which we may use or disclose your identifiable health information:
1. Public Health Risks. Our organization may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:
• maintaining vital records, such as births and deaths
• reporting child abuse or neglect
• preventing or controlling disease, injury or disability
• notifying a person regarding potential exposure to a communicable disease
• notifying a person regarding a potential risk for spreading or contracting a disease or condition
• reporting reactions to drugs or problems with products or devices
• notifying individuals if a product or device they may be using has been recalled
• notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult person served (including domestic violence) though we will only disclose this information if the person served agrees or we are required or authorized by law to disclose this information
2. Health Oversight Activities. Our organization may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
3. Lawsuits and Similar Proceedings. Our organization may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
4. Law Enforcement. We may release PHI if asked to do so by a law enforcement official:
• Regarding a crime victim in certain situations, if we are unable to obtain the person's agreement
• Concerning a death we believe has resulted from criminal conduct
• Regarding criminal conduct at our offices
• In response to a warrant, summons, court order, subpoena or similar legal process
• To identify/locate a suspect, material witness, fugitive or missing person
• In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)
5. Deceased Persons. Our organization may release PHI to a medical examiner or coroner to identify cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.
6. Research. Our organization may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when Internal or Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (C) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the PHI.
7. Serious Threats to Health or Safety. Our organization may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
8. National Security. Our organization may disclose your PHI to federal officials for intelligence and national security activities authorized by law.
9. Workers' Compensation. Our organization may release your PHI for workers' compensation and similar programs.

D. YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding the PHI that we maintain about you:
1. Confidential Communications. You have the right to request that our organization communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to the Program Director or Privacy Officer specifying the requested method of contact, or the location where you wish to be contacted. Our organization will accommodate reasonable requests. You do not need to give a reason for your request.
2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members, guardians, and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to the Program Director or Privacy Officer. Your request must describe in a clear and concise fashion:
a. the information you wish restricted;
b. whether you are requesting to limit our organization's internal use, outside disclosure or both; and
c. to whom you want the limits to apply.
3. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to the Program Director or Privacy Officer in order to inspect and/or obtain a copy of your PHI. Our organization may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our organization may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our organization. To request an amendment, your request must be made in writing and submitted to the Program Director or Privacy Officer. You must provide us with a reason that supports your request for amendment. Our organization will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the organization; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our organization, unless the individual or entity that created the information is not available to amend the information.
5. Accounting of Disclosures. All of our persons served have the right to request an "accounting of disclosures." An "accounting of disclosures" is a list of certain non-routine disclosures our organization has made of your PHI, e.g., for non-treatment, non-payment or non-operations purposes. Use of your PHI as part of the routine care in our organization is not required to be documented. For example, the therapist sharing information with the educator; the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. Also, we are not required to document disclosures made pursuant to an authorization signed by you. In order to obtain an accounting of disclosures, you must submit your request in writing to the Privacy Officer. All requests for an "accounting of disclosures" must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our organization may charge you for additional lists within the same 12-month period. Our organization will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact any Program Director or the Privacy Officer.
7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our organization or with the Secretary of the Department of Health and Human Services. To file a complaint with our organization, contact the any Program Director or the Privacy Officer. We urge you to file your complaint with us first and give us the opportunity to address your concerns. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
8. Right to Provide an Authorization for Other Uses and Disclosures. Our organization will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, however, that we are required to retain records of your care.

I understand my rights contained in the notice.
BY ENTERING MY NAME AND CHECKING THE BOX BELOW I AM AGREEING I HAVE BEEN OFFERED THE NOTICE OF PRIVACY PRACTICES FOR AUTHENTIC HAND THERAPY, LLC

I have the right to review the Notice of Privacy Practices prior to signing this consent and at any time while under the care of Authentic Hand Therapy, LLC. Authentic Hand Therapy, LLC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Heidi Wills at 724 S. Central Ave, Ste 107, Medford, Or 97501.

With this consent, Authentic Hand Therapy, LLC may:
Call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including examination findings, test results, among others.

Mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient billing statements as long as they are marked “Personal and Confidential.” Contact me by phone, mail, or email to participate in charitable events, patient appreciation days, educational seminars, health/wellness/fitness classes, or other marketing events to raise awareness, food donations, gifts, money, or promote pertinent products or services that might be useful to me.

E-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient billing statements. I have the right to request that Authentic Hand Therapy, LLC restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

I am consenting to allow Authentic Hand Therapy, LLC to use and disclose my PHI to carry out TPO and other approved uses as stated above. The Notice of Privacy Practices provided by the practice named above describes such uses and disclosures more completely. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Authentic Hand Therapy, LLC may decline to provide treatment to me.

BY ENTERING MY NAME AND CHECKING THE BOX BELOW I HEREBY GIVE CONSENT FOR AUTHENTIC HAND THERAPY, LLC TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI) ABOUT ME TO CARRY OUT TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS (TPO).

The goal at Authentic Hand Therapy, LLC is to provide you with caring and effective treatment. To fully benefit from therapy, we would like you to become familiar with our services in order for you to know what to expect from us and what we expect from you.

PHILOSOPHY OF CARE
· Our goal is to empower you with knowledge. By fully understanding your condition, you will be better able to participate in your own recovery. Feel free to ask questions about your diagnosis.
· We strive to create a relaxed and supportive environment. Please let us know how we can make you more comfortable.

TREATMENT
· In order to fully benefit from therapy, it is important to attend therapy sessions consistently and perform your self-care program as prescribed by your therapist.
· If you feel therapy is not meeting your needs, please bring it to our attention. We’ll be happy to modify your program to ensure a successful recovery.

UPCOMING APPOINTMENTS AND ATTENDANCE
· Please arrive on time for your appointments. If you are more than 15 minutes late, your appointment may need to be rescheduled.
· For treatment to be effective and covered by insurance, it is important for you to be treated consistently. If you are unable to attend an appointment, please call us at least 24 hours in advance to cancel and reschedule (preferably within the same week). At AHT we offer a number of ways to make it easy to attend your appointments, including in clinic visits, on-site visits (home, work, school, etc.), and virtual services, as well as appointment reminder calls, texts and emails.

No Show and Cancellation Policy

No Show or Late Cancellation (less than 24 hours notice), 1st occurrence:
We will contact you to review our No Show/Late Cancellation policy and attempt to reschedule your appointment.

No Show or Late Cancellation, 2nd occurrence:
You agree to pay a $50 missed appointment fee. We will contact you to inform you of your dismissal from hand therapy services and contact your referring provider and insurance company or payer to inform them of your dismissal.

Cancellation (more than 24 hours notice), 1st and 2nd occurrences:
We will contact you to review our Cancellation Policy and attempt to reschedule your appointment.


Cancellation, 3rd occurrence:
You agree to pay a $50 missed appointment fee. We will dismiss you from hand therapy services and contact your referring provider and insurance company or payer to inform them of your dismissal.

FOLLOW-UP VISITS WITH YOUR PHYSICIAN
· We periodically assess your progress and send reports to your physician. Please advise us of all upcoming appointments with your physician.

CHILDREN
· We understand that childcare is not always possible. If you are unable to have your child cared for during your next appointment, we would appreciate if you could bring a responsible family member or friend to watch your child in the waiting room. Our staff is not permitted to provide childcare.
· If you are unable to find suitable accommodations, please discuss this matter with us.

INSURANCE
· It is your responsibility to verify that hand therapy is covered by your insurance carrier. Please note that hand therapy is billed under either occupational or physical therapy when checking with your insurance company.
· It is also important to determine the number of visits and/or the dollar limit permitted in a calendar year.
· Co-payments, Co-insurances and deductibles should be paid at the time of service
· As a courtesy, within a week of your first appointment, our front office staff will contact your insurance company to verify therapy eligibility and benefits including the benefits for splints/orthoses that may be needed in your care. If your insurance company requires prior authorization, please ensure that this has been addressed by your physician/practitioner’s office.

We can be reached at 458-214-8881. If calling after hours, please leave a message on our voicemail. We will contact you as promptly as possible.

BY ENTERING MY NAME AND CHECKING THE BOX BELOW I AM STATING THAT I HAVE READ THE ABOVE PATIENT INFORMATION AND AGREEMENT AND WILL COMPLY WITH THE AGREEMENT.

Waiver of Liability

I fully understand and acknowledge that (a) the activities in which I will engage as part of the treatment provided by Authentic Hand Therapy, LLC and the physical/occupational therapy activities and equipment I may use as a part of that treatment have inherent risks, dangers, and hazards and such exists in my use of any equipment and my participation in these activities; (b) my participation in such activities and/or use of such equipment 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 Authentic Hand Therapy, LLC, and any other entity, person, or associate, 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 equipment, 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 Authentic Hand Therapy, LLC, 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 Authentic Hand Therapy, LLC 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 equipment 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 Authentic Hand Therapy, LLC

BY ENTERING MY NAME BELOW I AM AGREEING I HAVE READ THE ABOVE WAIVER AND RELEASE. IT IS MY INTENTION TO EXEMPT AND RELIEVE AUTHENTIC HAND THERAPY, LLC FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR ANY OTHER CAUSE.