Sunrise Physical Therapy Services, Inc.’s Legal Duty 

Sunrise Physical Therapy Services, Inc. is required by law to protect the privacy of your personal health information, provide a notice about our information and follow the information practices described in the notice.

 

USES AND DISCLOSURES OF HEALTH INFORMATION

Sunrise Physical Therapy Services, Inc. uses your personal health information primarily for treatment; obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example Sunrise Physical Therapy, Inc. may use your personal health information to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you.

Sunrise Physical Therapy Services, Inc. may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposed and for emergencies. We also provide information when required by law.

In any other situation, Sunrise Physical Therapy, Inc. policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke the authorization to stop future disclosures at any time.

Sunrise Physical Therapy Services, Inc. may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room and will be provided to you on your next visit.

 

PATIENT’S INDIVIDUAL RIGHTS

You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes. You may also request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. Sunrise Physical Therapy Services, Inc. will consider all such requests on a case by case basis, but the practice is not legally required to accept them.

CONCERNS AND COMPLAINTS

If you are concerned that Sunrise Physical Therapy Services, Inc. may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our practice manager at 805.644.1273

FINANCIAL AND PAYMENT POLICY

Welcome to Sunrise Physical Therapy Services, Inc., (SPTS). Thank you for choosing us.

We are committed to the success of your treatment. We are happy to discuss and answer questions you may have regarding your treatment and/or your financial obligations for your care. We request that you review all our policies carefully.

 

PRIVATE PAY/NO INSURANCE

• Full payment is due at time of service and will be collected prior to treatment. Please come prepared to pay each visit.

• You will be held personally responsible for no show fees or late cancellation fees as outlined in SPTS’s No-Show/Cancellation Policy.

 

WE ACCEPT CASH, CHECKS, CREDIT CARDS

Payments are due at check-in prior to seeing the therapist. If you schedule multiple visits in a week, you may pay in advance for the entire week’s co-pays. If you have a patient responsibility portion of the bill, which is quoted as a percentage, you will be expected to pay at each appointment. If you have a deductible that has not been met, you will be expected to pay at each
appointment. SPTS will supply you a payment receipt upon request. SPTS mails patient statements monthly. You will receive a statement for any unpaid balance on your account. We expect payment on receipt of your statement. If payment is not received a second notice statement will be mailed to you in the
subsequent month. If payment is still not received, you will receive a “Final Notice” patient statement. If we do not receive payment within 10 business days of our “Final Notice” patient statement, your account will be sent to our collection agency without further notice. If formal collections procedures become necessary you will be responsible for all additional costs
incurred.

Your insurance policy is a contract between you and your insurance company. In the unlikely case that your benefits do not cover our services, please remember that you are responsible for the total cost of your treatment. Our fees are meant to be reasonable and competitive and we are most happy to discuss them with you.

CONSENT FOR TREATMENT

Your SPTS physical therapist will complete an evaluation by examination and subjective interview. Your individualized treatment plan will be devised based on your evaluation. A variety of treatments can be used. I, the undersigned, do hereby agree and give my consent to Sunrise Physical Therapy Services, Inc. to furnish physical therapy care and treatment considered necessary and proper in evaluating or treating my physical condition.

ASSIGNMENT OF BENEFITS

I hereby authorize Sunrise Physical Therapy Services, Inc. to release all information necessary to secure payment concerning this treatment and hereby assign all payments from my insurance carrier directly to Sunrise Physical Therapy Services, Inc. I also agree that a photocopy is as valid as the original

We want to provide our patients with the highest quality of care and service.

We are committed to assist you in the restoration of your physical abilities. We know from experience to be successful in the care of our patients that our patients must also be committed to their own treatment. Therefore, adherence to the recommended number of treatments is an important component of your progress.

We take the subject of no-shows/cancellations very seriously. Attendance can make the differencebetween whether you succeed or fail in your restoration of your physical abilities. When you no show or cancel with late notice, three people are affected:

1. You, because don’t get the treatment you need as prescribed by your doctor and/or PT.
2. Your Physical Therapist- They had time reserved for you on their schedule and this is now a cost to the business.
3. Another patient who could have been scheduled for treatment if you had given proper notice.

We expect you to keep all your appointments, with the exception of serious emergencies. If you need to re-schedule an appointment, we require 24 hours notice. If this occurs, call our office and arrange for a make-up appointment. The make-up appointment should be in the same week, preferably the very next day.

For Worker’s Compensation patients we are required to forward documentation of any missed visits to your case manager and primary physician. In cases of repeated cancellations and/or no-shows we reserve the right to discontinue care due to noncompliance.

**We require 24 hour notice in the event of a cancellation. The charge for cancellation without proper notice is $75.**

This charge will NOT be covered by insurance, but will have to be paid
by you personally. This fee must be paid prior to receiving additional treatment.

By signing below I acknowledge I have read and understand Sunrise Physical Therapy Services (SPTS), Inc.’s Notice of Patient Information Practices. I am aware I can request a copy at any time. I understand that Sunrise Physical Therapy Services, Inc. may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I also understand that Sunrise Physical Therapy Services, Inc. will consider requests for restriction on case by case basis, but does not have to agree to requests for restrictions.

Any controversy, problem or dispute between the parties arising from or related to this Agreement or treatment which is not resolved by the parties shall be submitted to arbitration pursuant to the rules of American Arbitration Association. Arbitration shall be initiated by the written request of either party. The decision of the arbitrator shall be final and binding on the parties and the arbitration award may be entered and enforced in any court having jurisdiction of the subject and the parties.

Request for arbitration under this agreement shall be presented within the time permitted for filing a judicial claim for relief on the subject of the dispute by the applicable statute of limitations of the State of California. A claim or dispute not submitted timely shall be deemed waived.

Describe your pain on the pain drawing.

Use the appropriate symbols:

N	Numbness
|||	Stabbing
X	Burning
oo	Stiffness
...	Pins and needles
==	Dull Aching
SS	Cramps

Please rate your pain on a scale from 0-10, 0 being none and 10 being maximum pain you could experience

The Healthcare Insurance Portability and Accountability act of 1996 (“HIPPA”) is a federal program, which requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept confidential. This act gives you, the patient, significant new  rights to understand and control how your health information is used. “HIPPA” provides penalties for covered entities that misuse personal health information.

 

We are required by law to maintain the privacy of your protect health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

 

As required by “HIPPA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

 

We may use and disclose your medical records only for each of the following purposes: treatment, payment, health care operations;

 

·         Treatment means providing, coordinating, or managing health care and related services by one or more health care providers.

 

·         Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review.

 

·         Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and customer service.

 

I understand and have been provided, (see brochure at front desk), with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. If I have any further questions in regards to the Privacy Practices I can contact the privacy officer.

 

I understand that Sunrise Physical Therapy Services, Inc. is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

 

I further understand that Sunrise Physical Therapy Services, Inc. reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should Sunrise Physical Therapy Services, Inc. change their notice, they will send a copy of any revised notice to the address I have provided. I will advise Sunrise Physical Therapy Services, Inc. if I wish to have any restrictions to the use or disclosure of my health information:

 

I understand that as part of Sunrise Physical Therapy Services, Inc. treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including via fax.

It is my desire to participate in telehealth treatment/visits through Sunrise Physical Therapy Services, Inc. I have agreed to voluntarily participate in telehealth therapy visits and recognize that there are limitations to the services available through telehealth services compared to an in-person visit. This may include, but is not limited to, the inability of the therapist to perform an in person hands-on examination, assessment, observations, feedback, and treatment.

 

Potential Risks: I understand that it is not possible to accurately predict my response to a specific telehealth therapy modality, procedure, or exercise protocol. Therefore, Sunrise Physical Therapy Services, Inc. does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for during these telehealth visits. I understand that there may be other risks not known or not reasonably foreseeable at this time. Furthermore, there is a possibility that the telehealth physical therapy treatment may result in aggravation of existing symptoms and may cause pain or injury.  I understand that medical attention will not be immediately available in the event it should be needed and will seek care from my personal physician or other health care provider if I have any concerns about my physical condition or health.

 

Telehealth: I understand this telehealth visit entails use of digital photography, digital interactive sessions, and videotaping for my telehealth therapy visit.  I acknowledge that Sunrise Physical Therapy Services, Inc. has used reasonable efforts to implement the appropriate privacy and security measures through a third-party vendor to protect my protected health information (PHI). I hereby acknowledge and agree that there are potential risks associated with this type of telehealth therapy notwithstanding these measures. Therefore, I hereby release and hold Sunrise Physical Therapy Services, Inc.  harmless if any privacy, technical, security breach or unauthorized release of PHI information should these protection measures fail for any reason. I authorize the release of my telehealth therapy medical information to appropriate third parties as necessary for any insurance, or medically related purposes.

 

Acknowledgement: I have read this consent form and understand the risks involved in physical therapy and agree to fully cooperate, participate in all telehealth physical therapy procedures, and comply with the established plan of care.