Intake Form

Financial Agreement:

Thank you for choosing Willow Kids Physical Therapy as your care provider. We ask that you read and sign this form to acknowledge and agree to accept financial responsibility for services rendered by Willow Kids Physical Therapy.

I agree that I am legally responsible and agree to pay Willow Kids Physical Therapy for all fees, charges, and expenses incurred. I acknowledge and agree that I am ultimately responsible for the payment to Willow Kids Physical Therapy for any and all services rendered.

I understand that I am responsible for paying for each treatment session at the time the treatment is performed. 

I authorize my insurance/benefits carrier(s) to remit payment of benefits for any claim directly to Willow Kids Physical Therapy.

I understand that it is my responsibility to notify Willow Kids Physical Therapy of any insurance initial changes. Failure to do so may result in client being financially responsible for all charges. 

I agree to give at least 24 hour notice when cancelling an appointment with exceptions made for illness and other unexpected surprises that come with life and parenthood. It happens. I get it. 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU AND/OR YOUR CHILD MAY BE USED AND DIS-CLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice of Privacy Practices 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 and/or your child, including demographic information that may identify you and that relates to your past, present and future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by your physi-cian, therapist, 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 healthcare bills, to support the operations of the practice and any other uses required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate or manage your health 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 home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval/payment for treatment may require that your relevant protected health information be disclosed to the health plan to obtain approval/payment for the treatment.

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activ-ities of our practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing and conducting or arranging for other business activities. For example, we may disclose your protected health information to occupational therapy school students that see patients in our office.

We may also call you by name in the waiting room when your provider 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. We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required by Law, Public Health issues as Required by Law, Communicable Disease Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donation, Re-search, Criminal Activity, Workers’ Compensation, Military Activity and National Security. 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 out compliance with the requirements of Section 164.500.

Other permitted and required uses and disclosures will be made only with your Consent, Authorization or Opportunity to object un-less required by law. You may revoke this authorization, at any time, in writing except to the extent that you physician, provider or the provider’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

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 infor-mation 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, pay-ment or healthcare operations. You may also request that any part of you 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/provider is NOT required to agree to a restriction that you may request. If the physician/provider believes it is in your best interest to permit use and disclosure of you protected health information, your protected health information will not be restricted.

You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communication 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/provider 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 via mail of any changes. You then have the right to object or withdraw as provided in this notice.

For more information about HIPAA or to file a complaint, please contact:

The US Department of Health and Human Services Office of Civil Rights
200 Independent Avenue
SW Washington D.C. 20201