AAA Physical Therapy Intake & Consent Form

AAA Physical Therapy Intake & Consent Form

8975 Guilford Rd Ste 170, Columbia, MD 21046
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Telehealth or In-Clinic Care?

TelehealthIn-Clinic Care: AAA Physical Therapy at Nourishing Journey Wellness Center 8975 Guilford Rd Ste 170 Columbia, MD 21046
AAA Physical Therapy and this form are complying with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA is a U.S. legislation that aims to ensure that all medical patient private data is kept safe, secure and protected. HIPAA is enforced by the U.S. Department of Health and Human Services (HHS), and specifically, their Office for Civil Rights (OCR) division. HIPAA requires all professional enterprises (regardless of the type) that deal with the confidential information of medical patients to comply with HIPAA regulations by instituting certain safeguards and measures to protect patient data. This includes provisions to safeguard the privacy, storage and electronic exchange of private health information. Such information is termed Protected Health Information (PHI), and, while similar to Personally Identifiable Information (PII), constitutes private health information that relates to a specific patient.
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Telehealth or eVisit Patient Consent Form
The purpose of this form is to obtain your consent to participate in a Telehealth Consultation or Follow Up in connection with the following procedure(s) and/or service(s): PHYSICAL THERAPY

Nature of Telehealth Consult:

During the telehealth consultation:

Details of your medical history, examinations, x-rays, and tests will be discussed with other health care professionals through the use of interactive video, audio ad telecommunication technology.
A physical examination may take place.
A non-medical technician may be present in the telehealth studio to aid in the video transmission.

Medical Information & Records:

All existing laws regarding your success to medical information and copies of your medical records apply to this telehealth consultation. Additionally, dissemination of any patient identifiable images or information for this telehealth interaction to any other parties or entities shall not occur without your consent.

Confidentiality:

Reasonable and appropriate efforts have been made to eliminate any confidential risks associated with telehealth consultation, and all existing confidentially protections under state and federal law apply to information disclosed during this telehealth consultation.

Rights:

You may withhold or withdraw your consent to the telehealth consultation at any time without affecting your right to future care or treatment.

Disputes:

Risks, Consequences & Benefits: You have been advised of all the potential risks, consequences and benefits of telehealth. Your health care provider has discussed with you the information provided above.

IMPORTANT RULES & POLICIES
1. Late Policy: If I’m late more than 10-minutes to my appointment, I may be rescheduled or asked to wait for next available open time slot.
2. Co-pays, coinsurances, and/or deductibles are due prior to treatment starts.
3. Not showing for an appointment without notice may result in a $60 fee added to my account.
4. Cell phones must be shut OFF or silent. There is no recording audio/visual allowed in the practice.
5. Children requiring supervision are NOT allowed to attend sessions with you without prior authorization.
6. If you are experiencing any financial hardship, please notify us immediately so we can create a feasible payment program.
7. I declare under penalty of perjury in the State of Maryland that the insurance information is true and correct, this is not a third party (someone else) insurance, and that I am a direct beneficiary (self, spouse, child) of the policy holder.
8. We are here to help you make informed decisions regarding your payment options to cover the COC (Cost of Care), however, you are responsible for verifying your benefits with your health insurance if you wish to use that to cover your payments for services rendered. We offer a complimentary benefits verification with you, ask our Front Desk about it. You are also responsible for changes of your insurance, work compensation information, or auto / vehicular accident case with / without lawyer.
9. You may receive through text / email about blogs / podcasts / events and any other communication from AAA PT.
10. If for any reason you are NOT satisfied with the care received, please contact our administrator at 443-979-7171 or admin@aaaphysicaltherapy.com.
11. I was informed that billing information such as cost of care verification, statements and account balances are sent through a safe online portal and an email will be sent to notify for the link to access and make payments.

1. A HEALTH SCREEN may be conducted prior to setting an appointment ONSITE. Health screens are conducted for staff and patients.

2. Upon arrival (in the car), call us at 443-979-7171 to check in and perform a health screen over the phone. Temperature checks are done prior to commencement of ONSITE treatment. We ask that you stay home if you feel sick for everyone’s safety.

3. Wearing of Masks is encouraged for all staff and patients before entry to the clinic.

4. We have NO FRONTDESK AREA WAITING POLICY in place at this time.

5. Online check in (no manual sign in) is enforced to minimize contact.

6. Staying 6 feet social distancing inside the clinic unless treated hands on by your Physical Therapist with your permission.

7. Hand washing is REQUIRED before and after treatment by both patient and staff.

8. Sanitation and disinfection of equipment, tables, mats and contact surfaces every after use with hospital grade approved agents.

9. Daily disinfecting of the clinic with UV light, air purifier on throughout the day.

10. Our PTs continue to provide Telehealth care even if they are ONSITE.

11. Our PTAs and Techs continue to help us ONSITE and ONLINE.

12. NO WALK INS allowed at this time. SAME DAY APPOINTMENTS available. CALL AHEAD!
Guidelines & Procedures
CONFORME:

By affixing my signature below, I fully give permission to the answers that I have chosen through the Patient Authorization Record.

I confirm that I give consent to participate in a Telehealth Consultation or Follow Up in connection with the following procedure(s) and/or service(s) : PHYSICAL THERAPY.

I also confirm that I have read and understood the rules & policies, as well as the Guidelines & Procedures of AAA Physical Therapy.
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If patient is a MINOR, parent/guardian’s name:

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p. 443.979.7171

AAA Physical Therapy, LLC
admin@AAAPhysicalTherapy.com
8975 Guilford Rd Ste 170 Columbia, MD 21046

f. 667.200.5908

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AAA Physical Therapy Intake & Consent Form

NUTRITION:

SUPPORT STRUCTURE:

Patient Authorization Record

Telehealth or eVisit Patient Consent Form

IMPORTANT RULES & POLICIES

Guidelines & Procedures