Primary Insurance Company: blanks* Primary Insured Name: Primary Insured DOB: Relationship to Patient: Primary Insurance ID#: Primary Insurance Group #:
Secondary Insurance Company: blanks Secondary Insured Name: blanksSecondary Insured DOB:blankRelation to Patient: Secondary Insurance ID#: Secondary Insurance Group #
Your Health Information Rights
You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that Well Done Physical Therapy is not required to agree to the restriction that you requested.
You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request
You have the right to inspect and copy your health information.
You have a right to request that Well Done Physical Therapy amend your protected health information. Please be advised, however, that Well Done Physical Therapy is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s)and information about how you can disagree with the denial.
You have a right to receive an accounting of disclosures of your protected health information made by Well Done Physical Therapy LLC.
You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.
I have read the Privacy Notice and understand my rights contained in the notice. By way of my signature, I provide Well Done Physical Therapy with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice.
Cancellation/No Show Policy
We realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable, however, advanced notification allows us to fulfill other patient’s scheduling needs and keeps the clinic operating at its most efficient level. Due to our one-on-one 60-minute treatments, missed appointments are a significant inconvenience to your physical therapy, the clinic and other patients.
1. Please provide our office with 24-house notice to change or cancel an appointment. Patients who do not attend a scheduled appointment or do not provide 24-hour notice to change a scheduled appointment may be responsible for a $25 office visit charge. This charge cannot be billed to insurance and must be paid on or before the next scheduled appointment.
2. Certain accident claims adjusters expect regular attendance to physical therapy as a requirement of an approved treatment plan. If appointments are missed or cancelled on a regular basis it could affect the status of your claim. Your treatment plan has been established by your medical practitioners to get you back to your regular activities as quickly as possible. Missing appointments hinders that process and may end up prolonging recovery.
3. Due to the limited time slots available for therapy appointments, it is important that all patients attend their as-scheduled appointments. If you are unable to attend, it is expected that you call and inform us at (254) 300-7123 at least 24 hours prior to your scheduled appointment. If you arrive 10 minutes after your scheduled appointment time, your treatment may be decreased due to time constraints. As a policy, if you have 3 or more no-shows, we reserve the right to discontinue services.
For patients who provide a cell phone number a text message reminder will be sent as a courtesy to you to serve as a reminder of your upcoming appointments. This service is not intended to replace direct communication to our office for cancelation of appointments. You must contact our office or your missed appointment will be considered a no call no-show.
I have read and understand this policy.
HIPAA NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Well Done Physical Therapy is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.
WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU AND/OR YOUR DEPENDENTS FOR THE FOLLOWING REASONS:
We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations.
We may disclose your health information to your insurance provider for the purpose of payment or health care operations.
We may disclose your health information as necessary to comply with State Workers’ Compensation Laws.
We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care in the event of an emergency.
As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.
Judicial and Administrative Proceedings
We may disclose your health information in the course of any administrative or judicial proceeding.
It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.
Change of Ownership
If in the event that Well Done Physical Therapy is sold or merged with another organization, your health information/record will become the property of the new owner.