HIPAA Acknowledgement and Consent Form
I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly.
- Obtain payment from designated third-party payers.
- Conduct normal health care operations such as quality assessments or evaluations and physician certifications.
I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information (Available in the office in print form). I have reviewed such
Notice of Privacy Practices prior to signing this consent, and acknowledge that I have studied the Privacy Practices prior to signing this consent, and acknowledge that I have studied the Privacy Practices. 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 at any time at the address above to obtain a current copy of the Notices of Privacy Practices.
I understand that I may request in writing that this organization restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the organization is not required to agree to my requested restrictions, but if the organization does agree, then it is abound to abide by such restrictions.
I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent.
Consent and Statement of Financial Responsibility
1. CONSENT FOR TREATMENT: I consent to and authoize my physical therapist, occupational therapist and other healthcare professionals and assistannts who may be involved in my care, to provide care and treatment prescribed by and/or considered necessary or advisable by my physician(s)/health care provider(s). I acknowledge that no guarantees have been made to me about the results of treatment.
2. APPOINTMENT ATTENDANCE AGREEMENT: I understand the importance of attending therapy consistently and arriving promptly for my appointment. I acknowledge that I may be rescheduled if I arrive more than 15 minutes late for my scheduled appointment. I understand the importance of scheduling appointments in advance and acknowledge that appointment times given one week do not automatically follow through to subsequent weeks. I agree to provide at least 24 hours notice when I need to cancel or reschedule an appointment.
3. RESPONSIBILITY FOR PAYMENT: All co-payments and other fees are due at the time of service. I acknowledge that in consideration of the services provided to me by Access Rehab and Wellness Center, I am financially responsible for payment of my bill. I acknowledge that it is my responsibility to provide Access Rehab and Wellness Center with current insurance information (if usin one) and to familarize myself with my insurance plan and its policies. Any questions I have regarding my health insurance coverage or benefit levels should be directed to my health plan. My health insurance plan may provide that a portion of the charges and balance will remain my personal responsibility, such as my deductible, co-payment, co-insurance or charges not covered or denied by my health insurance, Medicare, or other programs for which I am eligible.
When you provide a check as payment in the clinic, you authorize us to use the information from your check to process a one-time Electronic Funds Transfer (EFT/ACH) or a draft drawn from your account , or to process the payment as a check transaction. When we use information from your check to make an EFT, funds may be withdrawn from your account as soon as the same day and you will not receive your check back from your financial institution.
Please note that refusal to sign this form does not change responsibility for payment in any way.
4. ASSIGNMENT OF BENEFITS (if using insurance): I hereby assign to Access Rehab and Wellness Center all my rights and claims for reimbursement under my health insurance policy. I agree to provide information as needed to establish my eligibility for such benefits.
5. ACCESS TO AND RELEASE OF HEALTH INFORMATION: I understand that Access Rehab and Wellness Center may document medical and other information related to my treatment in electronic and other forms and that such information will be used in the course of my treatment, for payment purposes and to support those who are caring for. I authorize my clinician(s) and Access Rehab and Wellness Center administrative staff to contact other healthcare professionals that may have information related to my prior and current health conditions and treatment. I acknowledge that I have received Access Rehab and Wellness Center. Notice of Privacy Practices and that it outlines how my health information will be used and disclosed and how I may gain access to and control my health information.
6. HIPAA CONSENTS: In compliance with HIPAA regulations, I consent to the following individuals receiving verbal information regarding the billing of my account:
I also authorize the release of appointment information left in a voicemail, answering machine, text message, email or thru the contact form on the website (shown at top of form with address), and understand that there is some level of privacy risk associated with these forms of communication.
7. CONSENT FOR EMERGENCY CONTACT INFORMATION:
Person to contact in case of an emergency:
By my signature below, I certify that I have read, understand, and fully agree to each of the statements in this document and sign below freely and voluntarily.
Access Rehab and Wellness Center, LLC complies with applicable Federal civil rights and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Cancellation Policy/No Show Policy For Physical Therapy Appointments
1. Cancellation/No Show Policy for Physical Therapy Appointment
We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we unable to schedule you for a visit, due to a seemingly "full" appointment book.
If an appointment is not cancelled at least 24 hours in advance, you will be charged a thirty-dollar ($30) fee. This will not be covered by your insurance company.
2. Scheduled Appointments
We understand that delays can happen, however we must try to keep the other patients and therapists on time.
If a patient is 15 minutes past their scheduled time, we may have to reschedule the appointment.
3. Cancellation/No Show Policy for Physical Therapy
Due to the block of time needed for therapy, last minute cancellations can cause problems and added expenses for the office.
If an appointment is not cancelled at least 24 hours in advance you will be charged a thirty-dollar ($30) fee. This will not be covered by your insurance company.
