Personal Profile

Do you have any of the following medical conditions:

In the past year, have you experienced any of the following symptoms? (If yes, please provide details)

Exercise:

 

On average, how many days a week do you perform moderate to vigorous intensity physical activity or exercise where your heart is beating faster and your breathing is harder than normal (such as a brisk walk)?

How many minutes per day or hours per week do you spend sitting?

Diet:

Sleep:

 Falls history:

Please indicate the intensity of your symptoms below by rating on a 0-10 scale. (0= no pain, 10= worst possible pain - Refer to the scale below for reference)

This notice describes how medical/health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

We are required by law to maintain the privacy of your health information; to provide you this detailed Notice of our legal duties and privacy practices relating to your health information; to notify you following a breach of the privacy or security of your unsecured protected health information and to abide by the terms of the Notice that are currently in effect. The effective date of this Notice is June 25, 2025.

I. USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

The following lists various ways in which we may use or disclose your health information for purposes of treatment, payment and health care operations.

For Treatment. We will use and disclose your health information in providing you with treatment and services and coordinating your care and may disclose information to other providers involved in your care. Your health information may be used by doctors involved in your care and by nurses, medical assistants and technologists and other care givers as well as by physical therapists, pharmacists, suppliers of medical equipment or other persons involved in your care as needed.

For Payment. We may use and disclose your health information for billing and payment purposes. We may disclose your health information to your representative, or to an insurance or managed care company, Medicare, Medicaid or another third-party payor. For example, we may contact your health insurance company to confirm your coverage, to request prior approval for services that will be provided to you, and/or for reimbursement of care provided to you.

For Health Care Operations. We may use and disclose your health information as necessary for health care operations, such as accreditation, management, personnel evaluation, education and training and to monitor our quality of care. We may disclose your health information to another healthcare-related entity with which you have or had a relationship if that entity requests your information for certain of its health care operations or health care fraud and abuse detection or compliance activities. For example, health information of many patients may be combined and analyzed for purposes such as evaluating and improving quality of care.

II. SPECIFIC USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

The following lists various ways in which we may use or disclose your health information.

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose health information about you to a family member, close personal friend or other person you identify who is involved in your care.

Emergencies. We may use or disclose your health information as necessary in emergency treatment situations.

As Required By Law. We may use or disclose your health information when required by law to do so.

Business Associates. We may disclose your protected health information to a contractor or business associate who needs the information to perform services for Connective Physical Therapy, LLC. Our contractors and business associates are committed to preserving the confidentiality of this information.

Public Health Activities. We may disclose your health information for public health activities. These activities may include, for example, reporting to a public health authority for preventing or controlling disease, injury or disability; reporting child abuse or neglect.

Reporting Victims of Abuse, Neglect or Domestic Violence. If we believe that you have been a victim of abuse, neglect or domestic violence, we may use and disclose your health information to notify a government authority, if authorized by law or if you agree to the report.

Health Oversight Activities. We may disclose your health information to a health oversight agency for oversight activities authorized by law, such as audits, investigations, inspections, licensure, disciplinary actions or for activities involving government oversight of the health care system or facility.

To Avert a Serious Threat to Health or Safety. When necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person, we may use or disclose health information, limiting disclosures to someone able to help lessen or prevent the threatened harm.

Judicial and Administrative Proceedings. We may disclose your health information in response to a court or administrative order. We also may disclose information in response to a subpoena, discovery request or other lawful process so long as the party seeking the information demonstrates reasonable efforts were made by such party to contact you about the request or to obtain a qualified protective order in accordance with 45 CFR section 164.512 (e)(1)(v).

Law Enforcement. We may disclose your health information for certain law enforcement purposes, including, for example, to comply with reporting requirements; to comply with a court order, warrant, or similar legal process; or to answer certain requests for information concerning crimes.

Research. We may use or disclose your health information for research purposes if the privacy aspects of the research have been reviewed and approved, if the researcher is collecting information in preparing a research protocol, if the research occurs after your death, or if you authorize the use or disclosure.

Disaster Relief. We may disclose health information about you to a disaster relief organization.

Workers' Compensation. We may use or disclose your health information to comply with laws relating to workers' compensation or similar programs.

Appointment Reminders. We may use or disclose health information to remind you about appointments.

Treatment Alternatives and Health-Related Benefits and Services. We may use or disclose your health information to inform you about treatment alternatives and health-related benefits and services that may be of interest to you.

III. USES AND DISCLOSURES WITH YOUR AUTHORIZATION

Except as described in this Notice, we will use and disclose your health information only with your written Authorization (such as, for certain types of marketing, sale of your protected health information For example, we will only use and disclose your health information for the purposes of marketing with your written Authorization. You may revoke an Authorization in writing at any time. If you revoke an Authorization, we will no longer use or disclose your health information for the purposes covered by that Authorization, except where we have already relied on the Authorization.

IV. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Listed below are your rights regarding your health information. Each of these rights is subject to certain requirements, limitations and exceptions. Exercise of these rights may require submitting a written request to Connective Physical Therapy, LLC. At your request, Connective Physical Therapy, LLC will supply you with the appropriate form to complete. You have the right to:

Request Restrictions. You have the right to request restrictions on our use or disclosure of your health information for treatment, payment, or health care operations. You also have the right to request restrictions on the health information we disclose about you to a family member, friend or other person who is involved in your care or the payment for your care. We are not required to agree to your requested restriction EXCEPT (i) if you request that we not disclose certain medical information to your health insurer and that medical information relates to a health care product or service for which we otherwise have received payment in full from you or on your behalf (from someone other than your health insurer), then we must agree to the request unless the disclosure is otherwise required by law and (ii) if you are competent you may restrict disclosures to family members or friends. If we do agree to accept your requested restriction, we will comply with your request except as needed to provide you emergency treatment.

Access to Personal Health Information. You have the right to inspect and obtain a copy of your clinical or billing records or other written information that may be used to make decisions about your care, subject to some exceptions. Your request must be made in writing. In most cases we may charge a reasonable fee for our costs in copying and mailing your requested information. You may request an electronic copy of any of your clinical or billing records that are maintained electronically.

Request Amendment. You have the right to request amendment of your health information maintained by Connective Physical Therapy, LLC for as long as the information is kept by or for Connective Physical Therapy, LLC. Your request must be made in writing and must state the reason for the requested amendment. We may deny your request for amendment if the information (a) was not created by Connective Physical Therapy, LLC, unless the originator of the information is no longer available to act on your request; (b) is not part of the health information maintained by or for Connective Physical Therapy, LLC; (c) is not part of the information to which you have a right of access; or (d) is already accurate and complete, as determined by Connective Physical Therapy, LLC. If we deny your request for amendment, we will give you a written denial including the reasons for the denial and the right to submit a written statement disagreeing with the denial and how you may file such a statement. In addition, you may request that Connective Physical Therapy, LLC provide your request for amendment and the denial with any future disclosures of the protected health information that is the subject of the amendment, in lieu of submitting the statement of disagreement.

Request an Accounting of Disclosures. You have the right to request an "accounting" of certain disclosures of your health information. This is a listing of disclosures made by Connective Physical Therapy, LLC or by others on behalf of Connective Physical Therapy, LLC, but does not include disclosures for treatment, payment and health care operations (except where such disclosures are through an electronic health record), disclosure made pursuant to your Authorization, and certain other exceptions. To request an accounting of disclosures, you must submit a request in writing, stating a specific time period. The first accounting provided within a 12-month period will be free; for further requests, we may charge you our costs.

Request a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time.

Request Confidential Communications. You have the right to request that we communicate with you concerning your health matters in a certain manner. We will accommodate your reasonable requests.

VI. CHANGES TO THIS NOTICE

We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all health information already received and maintained by Connective Physical Therapy, LLC as well as for all health information we receive in the future. We will provide a copy of the revised Notice upon request.

 

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 understand that this information can and will be used for the following (as described in the Notice of Privacy Practices):

1. Treatment: Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

2. Payment: Obtain payment from third party payers.

3. Health Care Operations: Conduct normal healthcare operations such as quality assessments, research, personnel evaluation, etc.

I have received, read and understand the Notice of Privacy Practices. I understand that this organization has the right to change its Notice of Privacy Practices at any time and that I may contact Connective Physical Therapy, LLC at any time to address any concerns regarding the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare options. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to obtain authorization before releasing written or verbal information regarding any patient. If the person is not named below, we are unable to speak to or release information to them.

You authorize Connective Physical Therapy, LLC and its staff to release information regarding your condition to the following people (name and phone number):

At Connective Physical Therapy, we want your focus to be on your care and recovery. To keep things simple and transparent, here's how payment works in our practice:

Payment Responsibility

We are currently a self-pay practice and do not bill insurance companies directly. This means patients are responsible for the full cost of each visit, with payment due at the time of service.

Payment Options - To make it easy, we accept:

• Cash (including Zelle)
• Personal checks
• All major credit cards (Visa, MasterCard, American Express, Discover)
• HSA and FSA cards

(A $2.00 processing fee is added when using a credit card or HSA/FSA card)

Flat-Rate Visits: Your agreed-upon flat rate is the same for both evaluation and follow-up visits. If rates ever change in the future, we will let you know before your next scheduled visit so you can decide how you'd like to proceed.

Additional Fees:

• Returned checks (non-sufficient funds): $30 fee
• Accounts unpaid after 30 days may be subject to a late fee

If you are experiencing financial hardship, please reach out to us in writing. We're happy to discuss options that may help.

Superbills: If you'd like to submit your visits to your insurance company for possible out-of-network reimbursement using a 'superbill' (an itemized invoice), please let us know at the beginning of your care - superbills won't be generated automatically. Please remember, all services must still be paid in full at the time of service, and reimbursement depends on your insurance plan.

By signing below, you confirm that you understand and agree to this payment policy.

I hereby consent to voluntarily engage in a physical therapy and wellness training program recommended for the improvement of my general health, function, and quality of life. I understand the intent of the program will be to provide rehabilitation, post-rehabilitation, fitness training, preventive conditioning, and/or sport performance enhancement.

To determine my physical capacity to participate in an individualized, goal-specific physical therapy and wellness program, I acknowledge that a comprehensive examination is required. The exam will require full disclosure of my present medical condition, past medical history, and physical assessment. Physical assessment procedures may include an examination of my vital signs, posture, range of motion, joint mobility, muscle flexibility, muscle strength, tissue integrity, neurovascular status, balance/coordination, and gait. I understand that I may be required to receive a physician's clearance to participate in an individualized physical therapy and wellness program if the evaluating therapist deems it necessary after the initial examination. I consent to these procedures and agree, if necessary, to acquire a physician's approval to participate in the physical therapy and wellness training program.

I understand that this program may benefit my physical fitness or general health. However, the program cannot guarantee any particular level of improvement. I recognize that involvement in physical therapy and wellness training sessions may allow me to learn proper ways to perform therapeutic exercises, use fitness equipment, and regulate physical effort.

I understand and have been informed that there exists the risk of bodily injury during physical therapy sessions including, but not limited to, injuries to skin, muscles/tendons, ligaments, joints and periarticular structures, and adverse responses such as abnormal blood pressure changes, lightheadedness, fainting, dizziness, abnormal heart rate changes and, in rare instances, heart attack, stroke, or death. Additionally, I understand that I must provide all medical related information to the owners, operators, agents, employees, therapists, and instructors of Connective Physical Therapy, including any problems, adverse symptoms, and/or desire to discontinue participation.

I have been informed that the information obtained in this program will be treated as privileged and confidential and will not be released to any person without my express written consent except as required by law. I agree to the use of any information for the purpose of consultation with other health /wellness professionals, including my doctor. Any other information obtained, however, will only be used by the owners, operators, agents, employees, therapists, and instructors of Connective Physical Therapy, LLC in the course of recommending interventions for me and evaluating my progress in the program.

I have been given the opportunity to ask questions as to the procedures of this program and, by my signature below, I fully consent to participate in physical therapy in consideration of the aforementioned advisements.

(Effective June 25, 2025)

At Connective Physical Therapy, LLC, your therapist sets aside a full hour for your care. To ensure that we can continue to provide personalized, one-on-one sessions, we require at least 24 hours' notice for appointment cancellations.

• Late cancellations: If less than 24 hours' notice is given, a $45 cancellation fee will be charged.
• First-time courtesy: We will waive this fee for the first late cancellation. Afterward, this policy will be enforced.
• Repeated cancellations: If 3 consecutive appointments are canceled with short notice, your upcoming visits may be placed on hold until consistent attendance can be established. Payment of the cancellation fee will be required prior to scheduling future sessions.

We appreciate your understanding and cooperation in respecting this policy, which helps us maintain the quality of care you deserve.

Please sign below to acknowledge that you understand and agree to this policy.