Informed Consent for Physical Therapy Services

Physical therapy is a patient care service that is provided in order to manage a wide variety of conditions. Services are provided to individuals of all ages regardless of gender, color, ethnicity, creed, national origin, or disability.

The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis and intervention by use of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum potential within their capabilities and to accelerate convalescence and reduce the length of functional recovery. All procedures will be thoroughly explained to you before you are asked to perform them.

Response to physical therapy intervention varies from person to person; hence, it is not possible to accurately predict your response to a specific modality, procedure, or exercise protocol. AMS Physical Therapy, 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. Furthermore, there is a possibility that the physical therapy treatment may result in aggravation of existing symptoms and may cause pain or injury.

It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns. It is your right to ask your physical therapist about the treatment they have planned based on your individual history, physical therapy diagnosis, symptoms, and examination results. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment.

Insurance
If you have medical insurance, we are happy to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance, and your understanding of our payment policy. You will be asked to update your demographic and insurance information annually, including providing our office with copies of your insurance card(s). We are required to obtain your signature for permission to release information to your insurance carrier annually. Our failure to obtain these updates could result in criminal and civil penalties and/or expulsion from your insurance plan. Please assist us in complying with your insurance requirements. We will gladly submit fees for your covered medical services to your insurance company. However, we expect payment of all services within 60 days. It may become necessary for you to pay your account in full if your insurance company fails to pay for services within 60 days. It is your responsibility to understand your coverage and benefits, including precertification’s, referral and authorization requirements. We, however, will assist you to ensure all plan requirements are met.

Payment for services 
Payment for services, including co-payment and deductible amounts, is due at the time services are rendered unless payment arrangements have been approved in advance by our staff. Our failure to collect these amounts may be a violation of our contract with your insurance company and may result in civil and criminal penalties and/or expulsion from your insurance plan. In addition, your failure to pay the required co-amounts is a violation of your financial responsibility for coverage. We accept cash, checks, MasterCard, VISA, Discover. Returned checks, balances older than 60 days, and failure to pay account balances as promised may be subject to external collection and additional collection fees, including attorney and other court fees. 

HMO/PPO 
It is your responsibility to obtain referrals from doctors if your insurance requires it. 

Medicare
We will file your claim with Medicare as a courtesy. If you desire, we will file your secondary insurance for you once we receive payment and the Medicare Explanation of Benefits. We  realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in management of your account. If you have any questions on the above information or any uncertainty regarding insurance coverage, please do not hesitate to ask us. 

PLEASE UNDERSTAND that we are not responsible for how your insurance company handles its claims or for what benefits they pay on a claim. We can only assist you in estimating your portion of the cost of treatment; we at no time guarantee what your insurance will or will not do with each claim. We also are not responsible for any errors in filing your insurance; once again we file claims as a courtesy to you. Some insurance companies arbitrarily select certain services they will not cover. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. 

Notice of Privacy Practices
This Notice of Privacy Practices describes how we may use and disclose your health information to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. The Notice also describes your rights with respect to your health information. Below is a brief summary of our obligations and your rights, followed by a more detailed description. Please review it carefully.

YOUR RIGHTS You have the right to:
• Receive a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Receive a list of those with whom we’ve shared your information
• Receive a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

YOUR CHOICES
•You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief

OUR USES AND DISCLOSURES
• We may use and share your information as we:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Conduct research
• Comply with the law
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

OUR RESPONSIBLITIES
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breech 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 give us permission in writing. If you give us permission, you can change your mind at any time. Let us know in writing if you change your mind.

PRIVACY OFFICER
For questions, complaints or for reasons otherwise noted in this Notice, contact Sejal Doshi at 805-383 0470 or via email at office@camarillophysicaltherapy.com.

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.