Forms and General Information

Forms

form_icon_small

Intake Form

Fall and Prescription Information Form

Fall and Prescription Information Form

Cancellation Form

Cancellation Form


General Information

Notice to Medicare Beneficiaries

Please be advised that Medicare has an annual financial limit or “cap” on outpatient physical and speech language therapy services.  The combined cap on these services changes annually.  This usually covers approximately 20 combined visits of physical and/or speech therapy.  It is very important that you notify us if you have received any outpatient physical and/or speech therapy this year.  There is usually an annual deductible for Medicare part B.

ALSO, PLEASE NOTE: Medicare does not pay for outpatient physical therapy if you have not been discharged from home health care.  Please let us know if you are being treated at home for any reason.  We are happy to answer any questions you may have.  You may also call Medicare at 1-800-MEDICARE (1-800-633-4227) or visit their website www.medicare.gov.


Notice of Privacy Practices

To our patients: This notice describes how health information about you (as a patient of this
practice) may be used and disclosed, and how you can get access to your health information.
This is required by the Privacy Regulations created as a result of the Health Insurance Portability
and Accountability Act of 1996 (HIPAA).

Our commitment to your privacy:

Our practice is dedicated to maintaining the privacy of your health information.
We are required by law to maintain the confidentiality of your health information.
We realize that these laws are complicated, but we must provide you with the following important
information:

  • How we may use and disclose your health information.
  • Your privacy rights.
  • Our obligations concerning the use and disclosure of your health information.

We may use and disclose your health information in the following ways:

  1. Treatment – Therapists and staff may use or disclose your health information in
    order to treat you or assist others in your treatment. Additionally, we may disclose
    your health information to others who may assist in your case such as your spouse,
    children or parents.
  2. Payment – Our practices may use your health information to bill and collect
    payment for the services you receive from us. We may provide your insurer with
    details regarding your treatment to determine if your insurer will cover (pay for)
    treatment. We may also use and disclose this information to obtain payment from
    third parties that may be responsible for such costs, such as family members. Also,
    we may use your health information to bill you directly for services and items.
  3. Disclosures require by law – Our practice will use and disclose your health
    information when we are required to do so by federal, state or local law.
  4. Appointment reminders – We may want to call you by phone for appointment
    reminder purposes. Please advise us if you do not want us to call and leave
    appointment reminder messages at your home, possible on your answering
    machine/voicemail, or with any coworker(s) at your workplace.

Use and disclosure of your health information in certain special circumstances:

  1. To public health authorities and health oversight agencies that are authorized by
    law to collect information.
  2. Lawsuits and similar proceedings in response to a court administrative order.
  3. If asked to do so by law enforcement officials.
  4. When necessary to reduce of prevent a serious threat to your health and safety, or
    to the health and safety of another individual or the public. We will only make
    disclosure to a person or organization able to help prevent the threat.
  5. To correctional institutions or law enforcement officials if you are an inmate or
    under the custody of a law enforcement official.
  6. For Worker’s Compensation and similar programs.
  7. If you are a member of the U.S. or foreign military forces (including veterans) and
    if required by the appropriate authorities.
  8. To federal officials for intelligent and national security activities authorized by law.

Your rights regarding your health information:

  1. You may request that our practice communicate with you about your health and
    related issues in a particular manner or at a certain location. For instance, you may
    ask that we contact you at home, rather than at work. We will accommodate
    reasonable requests.
  2. You can request a restriction in our use or disclosure of your health information for
    treatment, payment or health care operations. Additionally, you have the right to
    request that we restrict our disclosure of your health information to only certain
    individuals involved in your care of the payment of your care, such as family
    members and friends. We are not required to agree to your request; however, if we
    do agree, we are bound by our agreement, except otherwise required by law, in
    emergencies or when the information is necessary to treat you.
  3. You have the right to inspect and obtain a copy of the health information that may
    be used to make decisions about you, including patient medical records and billing
    records. You must submit your request, in writing, to our Privacy Officer.
  4. You may ask us to amend your health information if you believe it is incorrect or
    incomplete, and for as long as the information is kept by or for our practice. To
    request an amendment, your request must be made in writing and submitted to our
    Privacy Officer.
  5. You are entitled to receive a copy of this notice of privacy practices. You may ask
    us to give you a copy of this notice at any time. To obtain a copy of this notice,
    contact our Privacy Officer.
  6. If you believe that your privacy rights have been violated, you may file a complaint
    with our practice’s Privacy Officer, or with the Secretary of the Department of
    Health and Human Services. All complaints must be submitted in writing, and you
    will not be penalized for filing a complaint.
  7. Our practice will obtain written permission from you to disclose information in
    ways that have not been identified in this notice or are not permitted by these laws.
    Contact our Privacy Officer if you have any question.