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  • Assignment of Benefits to Harvest Physical Therapy DBA One Accord Physical Therapy


    This is a direct assignment of my rights and benefits under this policy.
    Harvest Physical Therapy
    1377 E. Florence Blvd. Ste. 151-L5
    Casa Grande, AZ 85122


    If my current policy prohibits direct payment to doctor, I hereby also instruct and direct you to make out the check to me and Harvest Physical Therapy and mail it to the above address for the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered.


    • This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay, in a current
    manner, any balance of said professional service charges over and above this insurance payment.
    • A photocopy of this Assignment shall be considered as effective and valid as the original.
    • I authorize the release of any medical or other information pertinent to my case to any insurance company, adjuster, or
    attorney involved in this case for the purpose of processing claims and securing payment.
    • I authorize the use of this signature on all insurance submissions.
    • I authorize Harvest Physical Therapy to deposit checks made in my name.
    • I authorize Harvest Physical Therapy to initiate a complaint to the Insurance Commissioner for any reason on my behalf.
    • I understand that I am financially responsible for all charges whether or not paid by insurance.
    • I have read and understand the OAPT Notice of Privacy Policy.

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  • Consent to treat and Important policies

    I,         consent and authorize One Accord Physical Therapy to provide therapy services that may be considered appropriate upon the professional judgment of my treating therapist, and or my referring physician. I also understand that I have the right to ask, and have questions answered prior to, during, and after treatments. This includes risks, benefits, alternatives, and the purpose of treatments. This consent is intended as a waiver of liability for such treatment excepting acts of negligence. I also have the right to deny any of the services recommended by my therapist. I also agree to ask questions for clarity if I do not understand the intention or benefit of the service, and I will not hold my therapist liable for my own assumptions if I choose not to ask clarifying questions of my therapist.

  • Notice of DBA, (Doing Business As) One Accord Physical Therapy is a DBA for Harvest Physical Therapy. As such many of our insurance contracts are listed under Harvest Physical Therapy. Please do not be confused if your EOB says Harvest Physical Therapy and not One Accord Physical Therapy, they are one in the same. Please feel free to ask for clarity if need be.

     


    IMPORTANT POLICIES:


    • Late Policy – Being late by more than 10 minutes will require you to either reschedule, or wait for the next available opening. There are no guarantees since openings due to cancellations can be unpredictable.
    • 24-Hour Advance Notice Fee- If you wish to change or cancel an appointment, we require a minimum of 24 hours advance notice. Anything less will result in a $35 fee charged to your account. It costs us money to make appointments available to you. Whether you attend or not, we will still accrue expenses.
    • No Shows- If you fail to show for an appointment without notice, all future appointments may be removed and a $50 fee will be assessed to your account.


    FINANCIAL POLICIES:
    Insurance coverage is never guaranteed. Although our office does verify coverage, online services only provide limited information. While we try to obtain accurate insurance benefits we are occasionally given incorrect information. If this occurs, you are responsible for any difference in what your insurance company quoted and what was actually paid.
    • I understand that my insurance company does not guarantee the information provided to One Accord Physical Therapy and that I will double-check my insurance benefits.

    • You understand that we are not obligated to provide the "Movement is Life" neuro-learning platform/program, PhysiApp, dry needling, shockwave therapy, blood flow restriction therapy, and any other non-covered service, that is not covered by your insurance company, as they are not considered traditionally covered physical therapy services.  We are able to offer non-covered services on a voluntary cash basis.  If you wish to only receive traditionally covered services we can refer you to a traditional physical therapy clinic within relatively close proximity to our clinic, as you are not required to participate in our non-covered services, and you have freedom of choice when it comes to receiving physical therapy services. 


    • Account Responsibility: Many people are under the impression that if they have insurance, it is the insurance company that owes One Accord Physical Therapy for their services. This is not the case. The insurance contract is between you and the insurance company; our relationship to you is as a patient to whom we are providing service.


    • Our responsibility:
    o To bill all claims to your insurance carrier(s) in a timely manner on your behalf.
    o To assist you in resolving any problems with your claim payment.

    • Your responsibility:
    o To provide us with current and accurate information to submit your claims correctly
    o To make certain if a current prescription from you doctor is needed for insurance
    purposes that you will obtain one, otherwise your claim could be denied.
    o To pay your co-pays, coinsurance or deductible payments at the time of service
    o To pay any additional amount owed as determined by your insurance carrier within 30 days of receipt of your first statement from us.


    • Unpaid accounts past 90 days may be sent to a third-party collection agency and may have an additional 1.5% interest charge attached. Additional collection fees and/or attorney fees will be your responsibility. A $25 processing fee will be added to all returned checks. We look forward to building a successful relationship with you that lasts a lifetime!

     

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  • Harvest PT DBA One Accord Physical Therapy-Statement of Privacy Notice

    Effective September 28, 2020

    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    • We may disclose your health care information to the other healthcare professionals within our practice for the purpose of treatment.
    • We may disclose your health information to your insurance provider for the purpose of payment of health care operations.
    • We may disclose your health care information as necessary to comply with State Workers Compensation Laws.
    • We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.
    • As required by law, we may disclose your health information to public health authorities for purposes related: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.
    • We may disclose your health information in the course of any administrative or judicial proceeding.
    • We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.
    • We may disclose your health information to coroners or medical examiners.
    • We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.
    • We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board.
    • It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.
    • We may disclose your health information for military, national security, prisoner, and government benefits purposes.
    • We may leave a message on an automated answering device or person answering the phone for the purposes of scheduling appointments. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment.
    • We may contact you by phone, mail, or email. This will be for the purpose of office updates and appointment reminders.
    • We may share your information within HIPPA compliant software and apps used to facilitate your care, including our documentation, billing, communication, exercise/video training platforms, and educational platforms.

    In the event we are sold or merged with another organization, your health information/record will become the property of the new owner.

    • You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that we are not required to agree to the restriction that you requested.
    • You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.
    • You have the right to inspect and copy your health information.
    • You have a right to request that we amend your protected health information.
    • Please be advised, however, that we are not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will provide with an explanation and information about how you can disagree with the denial.
    • You have the right to receive an accounting of disclosures of your protected health information made by us.
    • You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.
    • We reserve the right to amend this Notice of Privacy Practices at any time in the future and will make the new provisions effective for all information that it maintains. Until such an amendment is made, we are required by law to comply with this notice.

    We are required by law to maintain the privacy of your health information and to provide you with this notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about this notice or if you want more information about your privacy rights, please contact us by calling this office at 855.331.7522. You may also come in to seek additional information, or write us at: Harvest Physical Therapy ATTN: Compliance 1377 E. Florence Blvd. Suite 151- L5 Casa Grande, AZ . 85122.

    If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

    DHHS, Office of Civil Rights

    200 Independence Avenue, S.W.

    Room 509F HHH Building

    Washington, DC 20201

     

    I have read the Privacy Notice and understand my rights contained in the notice.

    By way of my signature, I provide the company above with my authorization and consent to use and disclose my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice.

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  • My normal blood pressure is:    /         *   

  • Medication:   * Dosage:   * Purpose:  * 
    Medication:   * Dosage:   * Purpose:  *  
    Medication:   * Dosage:   * Purpose: *  
    Medication:   * Dosage:   * Purpose:  *   
          *   
    ***List of medications may also be brought in at the time of appointment

  • Surgical History
    Region:    Surgery Type & Date:    
    Region:    Surgery Type & Date:    
    Region:    Surgery Type & Date:      
    Region:    Surgery Type & Date:    
    Region:    Surgery Type & Date:        
              

  • Past Medical History

     

  • Please specify other:      

  • Review of Systems: Are you currently experiencing any of the following?

  • On diagram below please use the following symbols to indicate what you are feeling and where:

    *On a desktop you will need to use the mouse to draw* 

    *On mobile device or tablet you can use your finger or stylus*

     

    Numbness  - - - -

    Pins & Needles  o o o o

    Burning  v v v v

    Aching  x x x x

    Stabbing  s s s s

     

    To undo an action on the Pain Diagram please use the left arrow function below

    *DO NOT USE ERASER OR X FEATURE, DIAGRAM WILL DISAPPEAR*

  • Patient Specific Functional Scale: Identify 3 to 4 important activities that you are unable to do or are having moderate to extreme difficulty doing. For each activity, rate the level of difficulty you have performing each activity using the scale 0-10 listed below. The higher the number, the more easily you can perform the activity. The lower the number, the more difficulty you have.

    Rating Scale

    Unable to perform the activity               Able to perform the activity at the same level as before

                      0         1       2       3        4           5       6        7       8         9        10

      

  • Activity:   *   Rating Today:   *   
    Activity:   *   Rating Today:   *   
    Activity:   *   Rating Today:   *   
    Activity:   *   Rating Today:   *   

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  • (FABQ) Waddell et al (1993) Pain, 52 (1993) 157 - 168


    Here are some of the things which other patients have told us about their pain. For each statement please circle any number from 0 to 6 to say how much physical activities such as bending, lifting, walking or driving affect or would affect your back pain.

    Please select the best answer:

    Completely disagree= 0          Unsure= 2,3,4,5     Completely agree=6

  • The following statements are about how your normal work affects or would affect your back pain

     Completely disagree= 0 Unsure= 2,3,4,5 Completely agree=6

  • FOR THERAPIST:
    Scoring Scale 1: Work – items 6, 7, 9, 10, 11, 12, 15. Scale 2: Physical Activity – items 2, 3, 4, 5.

    Source: Gordon Waddell, Mary Newton, Iain Henderson, Douglas Somerville and Chris J. Main, A (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability, Pain, 52 (1993) 157 – 168

  • PCS

    Everyone experiences painful situations at some point in their lives. Such experiences may include headaches, tooth pain, joint or muscle pain. People are often exposed to situations that may cause pain such as illness, injury, dental procedures or surgery.

    We are interested in the types of thoughts and feelings that you have when you are in pain. Listed below are thirteen statements describing different thoughts and feelings that may be associated with pain.

    Using the following scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain

     

    0–not at all         1–to a slight degree          2–to a moderate degree

    3–to a great degree              4–all the time

     

    When I’m in pain …

     

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