Bike Fit Intake Form

APPOINTMENT/POLICY INFORMATION

Patients do NOT need a doctor’s referral to obtain physical therapy for 12 visits or 45 days.

CLIENT APPOINTMENT CHECK-IN: Please arrive ten (10) minutes prior to your appointment to check in. If you have not completed your intake forms, or if you have other medical forms that you would like to provide us with, we will process them at that time. Payment is due at time of service, and will be collected at check- in. We accept credit cards, FSA/HSA cards, cash, and checks. To speed up intake processing, you may call ahead to provide your credit card number.

CANCELLATION POLICY: We require a minimum of 48 hours advance notice in order to cancel an appointment without incurring a late fee. Our office is open Monday through Saturday, and we are closed on weekends. Please refer to our website for further information about our hours. Clients will be charged $75.00/hour for appointments cancelled or rescheduled within 48 hours, and same day cancellations will be charged in full.

INVOICES/INSURANCE: Revolutions in Fitness is not listed as a provider under any medical insurers, and does not accept medical insurance or MediCare. If you require reimbursement for services from your insurance company, we will provide an invoice on request. If required, please fax (408-273-6564) or e-mail (office@revolutionsinfitness.com) your prescription/physician referral documentation prior to your appointment, or bring it with you to your appointment. (Patients do NOT need a doctor’s referral to obtain physical therapy from Revolutions in Fitness.)

HOME EXERCISE PHOTOS: Many clients have found it helpful to have photos taken of them doing prescribed home exercises or stretching during their appointments to ensure memory of proper form and technique. Bring a cell phone or camera to your session if you are interested in having photos available for your personal use.

WHAT TO BRING: Bring any relevant medical reports. Bring or wear cycling gear (jersey, shorts, shoes, gloves, and any orthotics that might be helpful).Bring your bicycle and any extra parts that may be helpful for the fit. If your bicycle uses unique thru-axles please bring any adapters you have to ensure we can attach the bike to the trainer.

NOTE: In an effort to provide the best possible service, we occasionally have new staff or students observe client appointments when we have new technology or equipment. We will inform you beforehand if this will apply to your appointment, and you may opt out of observation if you wish.

WHAT TO EXPECT FROM YOUR BIKE FIT 

Your Bike Fit session will include the following:

1. On-bike analysis – posture, pedaling efficiency, seat, cleat, and handlebar positions

2. Off-bike analysis – flexibility, extremity and core strength, balance, leg length

3. Bike adjustments – matching the bicycle to your body and goals

4. Exercise instruction – for improvements in cycling efficiency and personal health

A Bike Fit will enable the Client to feel more comfortable on his/her bicycle while riding, but will not correct underlying physical issues causing discomfort or pain. Often, a bicycle’s current fit is the large ‘final straw’ that finishes pushing the body into an unhealthy place. People frequently have underlying musculoskeletal weaknesses (like diminished flexibility, core strength, pedaling efficiency) their current bike fit reveals. A proper Bike Fit can accommodate such muscle and joint issues, minimizing or eliminating associated pain/discomfort; however, the underlying issues remain. For example, a chronically tight hamstring and weak core will frequently lead to back and neck pain. By changing a bicycle’s fit, such tightness/weakness can be accommodated, allowing the rider to feel better while biking. However, if the rider does a really hard or long ride, a lot of sitting, lifting or another activity that requires strength and flexibility, the issues may arise again. A Bike Fit that accommodates physical dysfunctions results in the healthiest, but not always the most efficient position or aerodynamics or power.

Therefore, many Clients schedule follow-up appointments to:

1. Recheck and progress their exercises;

2. Get physical therapy work to address tight areas;

3. Work on proper pedal mechanics on the bike;

4. Get further bicycle readjustments based on physical changes (e.g., increased flexibility and strength) that diminish injury as the largest consideration, allowing for more efficient on-bicycle positioning.

As part of the Bike Fit appointment, the possibility of follow-up sessions in helping the Client achieve their goals will be discussed.

HIPAA NOTICE OF PRIVACY PRACTICES (NOPP)

 

Purpose: 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.

 

This Notice of Privacy Practices (NOPP) describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

 

Uses and Disclosure of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law. Ways your protected health information may be used or disclosed include, but are not limited to, the following:

 

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage yourhealth care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Alternatively, we may disclose your protected health information to a physician to obtain a referral or prescription authorizing follow-up treatment, if needed.

 

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support business activities of our office and/or to your referring physician or allied health & wellness provider. These activities include, but are not limited to, quality assessment activities, employee review activities, practitioner training and licensing, marketing and fundraising activities. For example, we may disclose your protected health information to physical therapy students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physical therapist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

 

Your Rights

Following is a statement of your rights with respect to your protected health information.

 

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

 

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

 

Your physician is not required to agree to a restriction that you may request. Ifphysician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

 

We may use or disclose your protected health information without your authorization in the following situations (this list is not necessarily inclusive): as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donation, Research, Criminal Activity, Military Activity and National Security, Workers’ Compensation, Inmates, Required Uses and Disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirement of Section 164.500.

 

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object, unless required by law.

 

You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

 

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e., electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

 

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

 

Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

 

This notice was published and becomes effective on/or before April 14, 2003.

 

 

HIPAA PRIVACY Acknowledgement of Receipt of Notice of Privacy Practices (NOPP)

 

Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices (NOPP) or to document our good faith effort to obtain that acknowledgement.

 

* You May Refuse to Sign This Acknowledgement*

 

 

Evolution Trainers Liabililty Waiver

In consideration of the use of the premises and equipment at EVOLUTION TRAINERS, I agree on behalf of myself, my personal representatives, heirs, executors and agents to RELEASE AND DISCHARGE EVOLUTION TRAINERS from any and all liabilities, claims, demands and causes of action that I may hereafter have for injuries, death or damages that result from personal injury or damage to or loss of personal property arising out of, or in any way connected with, my use of EVOLUTION TRAINERS’ facility. This Waiver and Release includes, but it not limited to, claims arising from injury, death or damage caused by the negligence of EVOLUTION TRAINERS, improper maintenance of equipment by anyone, use of any exercise equipment which may malfunction or break, consumption or purchase of any food or beverages sold on site, my slipping or falling in and around the EVOLUTION TRAINERS premises, and /or hidden, latent or obvious defects of any EVOLUTION TRAINERS equipment. I also expressly agree to release and discharge EVOLUTION TRAINERS from any act or omission in rendering or failing to render any type of rescue, emergency or medical services to me. If any part, portion or provision of this agreement shall be held invalid, void or inoperative, that part, portion or provision shall be deemed excluded from this contract, and the remainder of this agreement shall remain in full force and effect. I have carefully read and understand the terms and conditions in this agreement. I am aware that this is a release of liability and I sign it of my own free will.

 

Acknowledgment and Assumption of the Risk Relating to Covid-19:

I understand that Evolution Trainers has put in place preventative measures to reduce the spread of COVID-19; however EVOLUTION TRAINERS cannot guarantee that I and or members of my household will not become infected with COVID-19. By signing this agreement I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I or members of of my household may be exposed or infected by COVID-19 while on the premises of EVOLUTION TRAINERS and that such exposure or infection may result in personal injury, illness, permanent disability and death. I understand that risk of becoming exposed to or infected by COVID-19 at EVOLUTION TRAINERS may result from the actions, omissions or negligence of myself and others including but not limited to EVOLUTION TRAINERS employees, independent personal trainers and other individuals using the premises. With Respect to COVID-19 I expressly acknowledge and agree that I am responsible for wearing my own personal protective equipment and to follow CDC guidelines on safe social distancing. My participation in this activity is purely voluntary and I elect to participate in spite of the risks.

This is a release of liability and I sign it of my own free will. My signature on the Release and Waiver of Liability acknowledges my acceptance of the terms of this agreement!

 

 

Revolutions in Fitness Liabililty Waiver

 

Please Read Carefully! This is A Legal Document Which Affects Your Legal Rights

Acknowledgment and Assumption of the Risk Relating to Covid-19:

I understand that Revolutions in Fitness has put in place preventative measures to reduce the spread of COVID-19; however REVOLUTIONS IN FITNESS cannot guarantee that I and or members of my household will not become infected with COVID-19. By signing this agreement I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I or members of of my household may be exposed or infected by COVID-19 while on the premises of REVOLUTIONS IN FITNESS and that such exposure or infection may result in personal injury, illness, permanent disability and death. I understand that risk of becoming exposed to or infected by COVID-19 at REVOLUTIONS IN FITNESS may result from the actions, omissions or negligence of myself and others including but not limited to REVOLUTIONS IN FITNESS employees, independent personal trainers and other individuals using the premises. With Respect to COVID-19 I expressly acknowledge and agree that I am responsible for wearing my own personal protective equipment and to follow CDC guidelines on safe social distancing. My participation in this activity is purely voluntary and I elect to participate in spite of the risks.

 

This is a release of liability and I sign it of my own free will. My typed name on the Release and Waiver of Liability acknowledges my acceptance of the terms of this agreement. 

Bike Fit Policy Agreement

 Please read the following statements carefully and sign at the bottom indicating your understanding. Thank you.

 Bicycle Retro-Fit (Bike Fit) adjustments frequently require a break-in period dependent upon the number and intensity of changes implemented, and amount of time the client rides his/her bicycle once adjustments have been made. Occasionally, downtime, if any, can be minimized or avoided by implementing incremental adjustments until the most efficient rider position is achieved.

 

1. Bike Fit Checkout List and Health Agreement

Bicycle Adjustments: Bicycle hardware (e.g., brakes, wheels, drive train, fastening devices for seat post/handlebar stem) is loosened/retightened as part of Bike Fit services. Client agrees to recheck any/all such adjustments to ensure revised bicycle position is secured and safe.
Break-In Period: Break-in period for bicycle adjustments is generally two (2) weeks in duration. During this period, Client will ride the adjusted bicycle using the small chain ring and adjusting riding volume, duration and intensity to below Client’s normal levels. Client’s original pain/discomfort should not increase during this break-in period. It is somewhat normal to experience differing sensations during break-in, especially muscular ones, but not pain. If Client experiences pain or has questions/concerns, please contact Revolutions In Fitness immediately.
Client Agreements: To the best of my knowledge, I am sufficiently healthy to participate in a Bike Fit appointment and related break-in period, since associated efficiency evaluation requires Client to undergo normal bicycling-related stress. I agree that if at any time I feel discomfort or unsafe during Bike Fit-related activities, I will communicate this to Revolutions In Fitness. I understand that it is my responsibility to notify Revolutions In Fitness of any changes in my medical and/or fitness condition that could impact my ability to exercise and train safely, including (without limitations) changes in matters covered by this questionnaire. I have been advised to consult with a physician before beginning any exercise, including Bike Fit-related activities, even if my answers within this questionnaire do not indicate existence of any specific risk factor(s).
2. Bike Fit Position Change Guidelines:

Ride on flat to rolling terrain and in easy gears.
Client should do self-massage (foam roller and the like) and daily stretching during the transitional period.
Client should record any changes he/she makes independent of those implemented during bike fit appointment(s).
3. Consent to Evaluation

I hereby consent to the evaluation of my bike fit by a bike fitter affiliated with Revolutions In Fitness.

 

4. Consent to Treatment

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I have been informed by Revolutions In Fitness of its Notice of Privacy Practices containing a more complete description of the uses and disclosure of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization to obtain a current copy of their privacy practices.

 

5. Consent to Contact Allied Healthcare and Fitness Providers

In order to ensure my optimal holistic care, I hereby grant permission for Revolutions in Fitness to contact the healthcare and fitness providers listed on my Patient Health Questionnaire.

 

6. Consent to Appointment/Policy Information

I hereby accept the terms outlined in Revolutions In Fitness’ Appointment/Policy Information document.

 

7. Patient/Client Responsibility

It is the patient’s/client’s responsibility to inform Revolutions In Fitness of all medical conditions, treatments, and medications at their initial evaluation.
It is the patient’s/client’s responsibility to inform Revolutions In Fitness if the patient/client is under the influence of any substance that may affect the safety of their treatment or injure someone else’s treatment (drugs, alcohol, blood thinners, etc.).
It is the patient’s/client’s responsibility to inform Revolutions In Fitness if the patient/client requires any clarification in understanding terms outlined in Revolutions In Fitness’ Appointment/Policy Information, and/or provide notice to Revolutions in Fitness of any concerns with these terms in advance of patient’s/client’s scheduled appointment.

By agreeing below, it indicates that I have read and understand each of the above patient/client policies of Revolutions In Fitness. I have addressed any concerns I have with these policies with the bike fitter. I further understand that by not agreeing with this form I may be refused service, as they are essential to the functioning of Revolutions In Fitness.