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
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