In Preparation For Your Appointment With Us

Patient Personal Information

First Name *

Last Name *

Date of Birth *

Preferred Phone Number *

Preferred Email Address *

Home Address *

City *

State *

Zip *

Cellphone *

Home Telephone

Emergency Contact Info

Emergency Contact Name *

Emergency Contact Cellphone *

Emergency Contact Home Telephone

Emergency Contact Email

Referring Provider Info (if applicable)

Referring Provider and Specialty *

Referring Provider Phone *

Referring Provider Fax

Referring Provider Address

Privacy Notice

Your Information. Your Rights. Our Responsibilities.

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.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record
Ask us to correct your medical record
Request confidential communications
Ask us to limit what we use or share
Get a list of those with whom we’ve shared information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint if you feel your rights are violated

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. We will never use your information for marketing without your explicit written permission.

In the case of fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again.

We will never sell your personal information.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you
Coordinate your care with other members of your healthcare team
Run our organization
Bill for your services

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

Preventing disease
Help with public health and safety issues
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or in response to a subpoena.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information, please visit: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Changes To the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

Effective date:

Privacy Official:

Email:

Phone #:

Release of Information

I hereby authorize the release of any information by telephone, email/fax, or in writing, including reports of diagnosis, treatment prognosis, recommendation, benefits payable, as well as any other data pertinent to my treatment, by Equipoise Occupational Therapy, PLLC to the physician who referred me for therapy, and to any organization responsible for payment of my account. I also authorize the release of any information by telephone or in writing for utilization and quality review purposes.

Please Provide any Medical Providers You Wish Us To Release Information To

Notice of Privacy Practices

I acknowledge receipt of the Notice of Privacy Practices from Equipoise Occupational Therapy, PLLC. I understand that the Notice of Privacy Practices provides information about how Equipoise Occupational Therapy, PLLC may use and disclose my protected health information. I have reviewed it and understand that the Notice of Privacy Practices is subject to change. If the Notice is changed, I may request a revised copy.

Assignment of Insurance Benefits

I hereby authorize that the payment of authorized benefits be made directly to Equipoise Occupational Therapy, PLLC of any services that are reimbursable by Medicare or my specific insurance plan if applicable.

Consent for Treatment

I hereby consent to such treatment procedures and patient care which, in the judgment of my therapist and/or physician, may be considered necessary or advisable while I am a patient of Equipoise Occupational Therapy, PLLC.

Guarantee of Account

I hereby guarantee payment for any and all services rendered to me which are not covered or allowable by Medicare or my specific insurance plan, together with collection costs, including reasonable attorney fees. I also understand that all bills are due and payable upon presentation. I understand that the client responsibility portion of my bill shall be due and payable at time of services. I understand that I am personally responsible for full payment of all charges including Medicare or my specific insurance plan denials, deductibles and copayment fees. I understand that Equipoise Occupational Therapy, PLLC does not submit to any other insurances, unless negotiated prior to start of service. I understand that I will be provided with an invoice for services not covered by Medicare or my specific insurance plan in which I can submit my own insurance for reimbursement in consideration of services rendered to me by Equipoise Occupational Therapy, PLLC.

Medicare

I hereby certify that the information given by me in applying for payment under title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any such information needed for this or a related Medicare Claim. I request that the payment of authorized benefits be made on my behalf. I understand that I am responsible for any health insurance deductibles and co-insurance. I understand that I cannot receive Medicare Part B services in the home if I am currently on Home Health under Medicare Part A and or on Hospice Care. I understand that services must be skilled and medically necessary to be covered by Medicare Part B. I understand Medicare will pay for 80% of the allowed amount, and I am responsible for the remaining 20% if I do not have a secondary insurance. I understand that Equipoise Occupational Therapy, PLLC will notify me prior to charging my credit card for any outstanding balance(s) by email and/or mail.

Appointment Cancellation/Rescheduling Policy

I hereby understand that I must inform my treating therapist of the need to cancel or reschedule an appointment prior to their arrival at my home. If I should repeatedly not do so during the course of my treatment I understand that Equipoise Occupational Therapy, PLLC may need to make alternative arrangements and reserve the right to discontinue services.

Financial Responsibilities

I hereby understand that I will be notified of my Out of Pocket Expense, my Co-payment, and my Deductible according to my current insurance policy, prior to receiving any treatments. I will have the opportunity to forgo treatment if I do not wish to make those obligatory payments to Equipoise Occupational Therapy, PLLC.

I understand that in accordance with the No Surprises act I will be provided with a Good Faith Estimate (GFE) prior to the beginning of my treatment. At which time I can decide to decline moving forward with treatment should I so choose.

By signing this document, I acknowledge my consent to the above. *

I have read and agree to the policies stated above

Signature Agreeing To All Policies *

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I hereby grant permission to Equipoise Occupational Therapy, PLLC to... (Check all that apply)

use photographs/video footage taken of me for use on associated websites, emails, fliers and any promotional ads.

send me a survey at the time of my discharge to obtain my feedback regarding my care.

utilize my written testimonials, quotes, and other written material for use on associated websites, emails, fliers and any promotional ads.

I hereby waive any right to inspect or approve the finished photographs/video footage, printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photographs/video footage and written material.

Yes

I hereby agree to release, defend, and hold harmless Equipoise Occupational Therapy, PLLC and its affiliates from and against any claims, damages or liability arising from or related to the use of the photographs/video footage, written statements, testimonials, quotes, including but not limited to any misuse, distortion, blurring, alteration, or use in composite form, either intentionally of the finished product, its publication or distribution. I will notify Equipoise Occupational Therapy, PLLC verbally or in writing if I choose to rescind my permission as detailed herein. By signing here I acknowledge my consent to the above.

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Email and Texting Messaging Agreement

Equipoise Occupational Therapy, PLLC values communication between therapists and clients.

We appreciate having the ability to communicate with you by email or text messaging as this is often the most convenient method for both therapists and clients. However, it is possible that email and text messaging security can be compromised, and it is beyond the control of Equipoise Occupational Therapy, PLLC to maintain the security of communications beyond using routine internet safety practices and safeguards. You may opt out of text messaging or email communications at any time by communicating with us about your preferences. By opting out of texts or emails you will be opting out of our appointment reminder system as well.

In Regards To The Email and Text Messaging Agreement *

I understand the need for my therapist to communicate with me and will notify them if I wish to update my preferences for email and texts

Informed Consent Form

You have consulted with Equipoise Occupational Therapy, PLLC and have decided to receive therapy services. It is important that you, the client, read this consent form carefully and obtain answers to any questions that you may have.

Physical and Occupational Therapy: Physical therapy involves several methods of evaluation and treatment. We use a variety of procedures and treatments to help us try and improve your physical and psychosocial function. As with all forms of medical treatment, there are benefits and risks involved. Patient responses to a specific form of treatment can vary widely from patient to patient, and it is not always possible to predict responses to a given form of treatment. There is a risk that your treatment may result in pain, injury, or aggravation of a previous condition.

You have the right to inquire as to the form of treatment based upon your history, diagnosis, and symptoms.

You may discuss with your provider the potential risks and benefits of a specific treatment and possible alternative treatment.

You have the right to decline treatment at any time or during your treatment sessions.

Your therapist will answer questions you may have regarding a given course of treatment, type of exercise or treatment method, associated risks, and possible alternatives.

This consent form is based upon your informed decision to participate in the proposed treatment plan for therapy services. The therapist identified on this form has discussed with me in words that I can understand, my diagnosis, conditions, reasons for and benefits of the plan of care, the reasonable likelihood of success, the possible material risks of not following the plan of care, the possible risks associated with the plan of care, and possible alternatives and risks associated with those alternatives. The therapist identified on this form and I have discussed my goals of recovery and potential problems that might arise during treatment. I have decided not to participate in alternative treatments at this time. I understand there are risks associated with therapy as described above. I am giving this consent with the understanding that any treatment or services involve some risks and hazards, and that no guarantees have been made to me.

I acknowledge that services may be provided to me by another therapist other than identified on this form or that have been assigned to me.

Patient/Authorized Guardian Signature Agreeing To Informed Consent Policy *

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