Welcome and thank you for choosing Old Bull Sports Medicine and Rehabilitation for your physical therapy needs.
Florida Law and the State of Florida Physical Therapy Board does not require patients to have a written Referral for Physical Therapy for an initial evaluation and up to 30 days of treatment by a physical therapist. However, patients are required, after 30 days, to obtain a written Referral for Physical Therapy from a licensed medical person (MD, DO, DC, DDS, DPM, ANP, PA). It is your responsibility to obtain and maintain a current referral after 30 days of treatment.
As a courtesy to others and our Therapists and to other patients trying to get scheduled, we require a 12-hour (or greater) notice for cancellations. This allows others on waiting lists to be seen. Only emergencies or illnesses are excusable. The full session price will be billed if this cancellation policy is violated.
CONSENT TO TREATMENT
Old Bull Sports Medicine and Rehabilitation is a movement-based and hands-on Physical Therapy clinic. Treatment consists of manual therapy techniques and treatment forms that are published or otherwise publicly known, as well as highly specialized therapeutic exercise, neuromuscular re-education, bone and soft tissue manipulation, dry needling, myofascial release, and other treatment modalities may be used.
Some of the hands-on treatment techniques require deep pressure which may cause bruising and periods of increased soreness which may last from 1-72 hours. Symptoms may also change and move to other parts of the body. This is not unusual and is rarely a concern, however, please ask if you have any concerns or questions.
The number of treatments needed and recovery time can vary widely due to the age of injury, number of times injured, age of patient and many other contributing factors.
I have read and fully understand the above statements. I understand the nature of the treatments at Old Bull Sports Medicine and Rehabilitation LLC and I authorize the fully trained staff to use treatment techniques as deemed necessary for my safe and effective recovery.
Before we begin services, please sign below indicating you have read, understand and agree to the following payment policies.
You agree to be financially responsible for all charges regardless of any applicable insurance or benefit payments, third-party interest, or the resolution of any legal action or lawsuits in which you may be involved.
Direct Pay and Out-of-Network Policy. Old Bull Sports Medicine and Rehabilitation is a fee-for-service clinic. This means that Old Bull Sports Medicine and Rehabilitation is not “in-network” with any private health plans. Payment is due at the time of service, regardless of using cash pay or using Out-of-Network Benefits. Depending on your Out-Of-Network plan benefits, you may be reimbursed directly from us or your insurance company for your sessions.
We accept cash, personal checks, and credit cards.
Medicare Policy. If you are a Medicare beneficiary, you understand that our licensed physical therapists are not enrolled as Medicare providers. Medicare has onerous technical and administrative requirements that must be met for services to be considered medically necessary covered benefits. We believe those requirements take unnecessary time away from the services we provide. Since the documentation and administrative processing of our services are not designed to meet Medicare’s covered benefit requirements and we are not Medicare enrolled providers, our services will not be covered (paid) in full or in part, by Medicare (including Medicare Advantage Plans) even if the same services might be considered covered benefits when provided by a Medicare enrolled provider.
We will not submit claims to Medicare on your behalf or provide you with a statement or billing codes that you can submit to Medicare yourself. If you want Medicare to pay for any services that might be considered covered benefits, you should seek those services from a Medicare enrolled provider.
By choosing to receive our services after being fully informed of these facts, you are agreeing, of your own free will, that you do not want Medicare involved in payment for your physical therapy services at Old Bull Sports Medicine and Rehabilitation. You agree to pay privately for the services you receive from us even if those services might be covered by Medicare if provided by a Medicare enrolled provider.
You also understand that since we are not enrolled Medicare providers and our documentation and administrative processes do not meet the technical requirements for Medicare to cover the services we provide, our services are not subject to Medicare’s maximum allowable charge.
You agree that you, your caregivers, family members, authorized representatives or power of attorney will not, under any circumstance, submit our claims, invoices, receipts, statements, or treatment notes to Medicare, a Medicare Advantage Plan, or to any primary-payer private insurance for reimbursement or to obtain a denial for a Medicare supplemental insurance plan.
Privacy Rights. You have a right to privacy under the Health Insurance Portability and Accountability Act (HIPAA) that includes restricting disclosure of your records and claims to your health plan, including Medicare, if you pay privately for your services at the time of service. By paying for your services at the time of service, we assume you are exercising this right to privacy and we will not disclose your medical records to any third party, including your health insurance carrier or Medicare. If you want your records disclosed to any third party in the future, you will need to obtain and sign our Disclosure to Release Protected Health Information form before we will disclose your health information.