HIPAA ACKNOWLEDGEMENT/CONSENT FORM
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:
· Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
· Obtaining payment from third party payers (e.g. my insurance company);
· The day-to-day healthcare operations of your practice.
I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Pratices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.
I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
To comply with HIPAA, you must be 18 years of age to sign.
Welcome to Capital Region Physical Therapy. We are happy that you are here so we can help you move better and feel better. We look forward to working with you to improve your overall mobility. To get the maximum benefit from your treatment please make note of our office procedures and policies.
1. Wear comfortable clothing to your appointment that allows you to move around freely. A changing room is available if needed.
2. Please avoid using your cell phone during your appointment. This allows you and your therapist to focus entirely on your care.
3. Copayments are due at the time of your appointment. If you have a deductible or a secondary insurance, you will be billed.
4. Please arrive on time for all appointments. We have set aside a specific time for your care that allows your therapist to provide one-on-one attention to your needs.
5. If you need to cancel or change your appointment time, please do so at least 24 hours prior to your scheduled appointment time. See the cancellation/no show policy below.
6. If you have any questions about your care, please ask us. We strive to create a therapeutic alliance with our patients to help you attain your physical therapy goals.
Cancellation/No Show Policy
In order to provide outstanding service to all of our patients, kindly provide at least 24 hours’ notice prior to cancelling or making changes to your appointment time. This enables us to offer that appointment slot to another patient who requires our services. If proper notice is not given for an appointment cancellation or alteration, we reserve the right to charge you a $25.00 cancellation fee.
If you do not show up for your appointment time, you will be charged a $25.00 no show fee, regardless of your insurance type (Managed Care Medicaid, private insurance, Worker’s compensation, or a No-fault insurance company). If you have worker’s compensation or no-fault insurance, your case manager will be notified of your missed appointment.
Patient Insurance Waiver and Notice of Responsibility
As a consumer of medical service, you may have an agreement with an insurance carrier to assist with payment with your medical care. Capital Region Physical Therapy, PLLC, maintains agreements with various insurance carriers. Should we participate with your insurance carrier, we will submit claims to your insurance provider. Your signature on this form authorizes us to do so. If your insurance carrier (for whatever reason) chooses not to satisfy your bill in full or reverses payment at any time, you understand and accept complete personal responsibility for any payment due.
It is your responsibility to know your insurance benefits. This may include any exclusions or prior authorizations required by your insurance company. It also may include a limit on your physical therapy sessions allotted per your insurance contract. By signing this agreement, you acknowledge that you understand your individual insurance benefits and agree to abide by the provisions of your policy.
Please note, Capital Region Physical Therapy, PLLC DOES NOT participate with Medicaid or United Healthcare Community Plan. We also DO NOT accept Medicaid as a secondary insurance. By signing this agreement, you acknowledge and accept responsibility for any payments that you incur during your treatment at Capital Region Physical Therapy, PLLC.