[POLICY & PROCEDURE MANUAL] The forms, documents and policies contained in this manual have been compiled by Iris Kimberg, MS PT OTR. It is available as a PDF file ($160), CD ($170) or as a hard copy ($190). Regardless of the format you purchase it in, you will automatically also recieve the manual as an editable word document so that you can modify it to suit your individual practice. * All practices are unique and reflect the individuals that are their creators. Yet there are commonalities that must be present in all practices by virtue of the fact that we are all compelled by similar professional practice acts, work and professional ethics as well as state and federal regulations including OSHA and HIPAA. The purpose of this book is to offer generic guidelines, policies and forms from which a therapist can then customize their own policies, procedures and forms to best meet their individual practices. Remember that policy and procedure manuals should be reviewed yearly and updated as often as necessary to reflect current standards of practice, new regulations and any changes in state and federal law. All therapists purchasing this will also be emailed a copy as a word document so that you can customize the forms for your practice 2011 ... Compiled by Iris Kimberg,MS PT OTR
Transcript
[POLICY & PROCEDURE MANUAL]The forms, documents and policies contained in this manual have been compiled by Iris Kimberg, MS PT OTR. It is available as a PDF file ($160), CD ($170) or as a hard copy ($190). Regardless of the format you purchase it in, you will automatically also recieve the manual as an editable word document so that you can modify it to suit your individual practice. * All practices are unique and reflect the individuals that are their creators. Yet there are commonalities that must be present in all practices by virtue of the fact that we are all compelled by similar professional practice acts, work and professional ethics as well as state and federal regulations including OSHA and HIPAA. The purpose of this book is to offer generic guidelines, policies and forms from which a therapist can then customize their own policies, procedures and forms to best meet their individual practices. Remember that policy and procedure manuals should be reviewed yearly and updated as often as necessary to reflect current standards of practice, new regulations and any changes in state and federal law. All therapists purchasing this will also be emailed a copy as a word document so that you can customize the forms for your practice
2011
...Compiled by Iris Kimberg,MS PT OTR
WHY THIS BOOK
All practices are unique and reflect the individuals that are their creators. Yet there are commonalities that must be present in all practices by virtue of the fact that we are all compelled by similar professional practice acts, work and professional ethics as well as state and federal regulations including OSHA and HIPAA.
The purpose of this book is to offer generic guidelines, policies and forms from which a therapist can then customize their own policies, procedures and forms to best meet their individual practices. This policy and procedure manual can be the beginning from which you can build the infrastructure of your practice. A successful practice needs to have a strong (non clinical) base in addition to offering the consumer sound clinical skills. As your practice grows and changes new policies and forms will be incorporated into your practice. Business policies have to also relate to your commitment to your clients, and your expectations from your clients.
Remember that policy and procedure manuals should be reviewed yearly and updated as often as necessary to reflect current standards of practice, new regulations, changes in state and federal law, along with any requirements of contracts you may enter into. Think of this manual as a “living document” , not something to be taken off a shelf and dusted every year.
Upon request, anyone who has purchased this book can request a copy to be sent via e-mail so that all materials can easily be down loaded and customized for your individual practice.
DISCLAIMER: The information presented represents the view of the individual presenter and is offered for educational purposes only. While intended to provide accurate information on the subject matter listed, this is sold and /or given out at workshops with the understanding that the presenter is not engaged in offering financial or legal advice, which can only be obtained from professionals credentialed in these areas.
SECTION ONE: FORMSFOR DIRECT PATIENT CARE:1. Initial Intake Form – Generic for Adults and Specific to Pediatrics2. Generic Evaluation Forms (Pediatric and Adult Practices)3. Generic Progress Re-evaluation Note4. Generic Discharge Form5. Assignment of Benefits Form/Patient Notification of
Billing/Cancellation/Discontinuance of Services Policy/Financial Policy Form6. Medicare Beneficiary Form7. Authorization for Release of Confidential Information8. Notice of Patient Privacy Practice/ Patient Information Consent Form9. Patient Satisfaction Survey10. Referral Source Satisfaction Survey11. Photo/Video Release Form / Waiver Form for Onsite Classes/Permission Slip for
Caregivers
SECTION TWO: FORMS/ POLICY STATEMENTS FOR GENERAL OFFICE PROCEDURES
1. Incident Reporting and Form2. Child Abuse2. Confidentiality, Release and Handling of Information including HIV Information3. Confidentiality for Emails/Faxes4. Emergency Preparedness Plan5. Health and Safety Issues Including Universal Precautions, Infection Control/
Handwashing Procedures6. HIPAA Policy and Procedures7. Rehabilitation Update/Documentation for Medicare Patients8. Clinical Chart Review FormSECTION THREE: FORMS FOR HIRING THERAPISTS/NON CLINICAL STAFF1. Application Form, Orientation and Minimum Requirements of Therapists2. Reference Forms3. Clinical Competency Review Form4. Employee Health Assessment5. Hepatitis B Consent/Decline Form6. Freedom from Impairment Form7. On Site Clinical Competency Form8. Sample Employee Handbook9. Code of Ethics - OT, PT STSECTION FOUR: BOILER PLATE GENERIC CONTRACTS1. Sample Temporary Personnel Services Agreement2. Sample Home Care Personnel Services Agreement3. Sample Contract for School District Service Provision
Iris Kimberg MS PT, OTR has worked in the non-clinical aspect of therapy for the past 27 years. She transformed a one person solo practice into a multimillion dollar rehabilitation agency that she later sold to a public entity. After 9/11, Iris, a longtime downtown resident formed a fund, The Downtown Therapists Assistance Project, to aid the fourteen physical and occupational therapy practices located within the vicinity of the World Trade Center. She raised over $35,000 for them, mostly donations from therapists across the country. This past fall, she organized a drive in NYC on behalf of Operation Medical Library to help replenish the medical libraries that have been destroyed in Afghanistan over the last 30 years.
Iris now enjoys sharing her expertise with others in the field through workshops, seminars and private consultations. She is a Professor at Columbia University DPT program, teaching a marketing and business entrepreneurship and has also guest lectured at both Touro College and Long Island University. Since 2004, she has been Merion Publication’s (parent company of Advance Magazine) business columnist, writing over 70 columns on business practice and management. Iris regular participates as a speaker in both NYSOTA and NYPTA conferences. She was a panelist at the March 6, 2005 symposium The Crisis in Reimbursement held at the NYU Department of Occupational Therapy. More recently, Iris was a keynote speaker at the Fall 2009 and 2010 NYSOTA Conference and at the Fall 2010 Private Practice Section of the NYPTA Conference in Washington D.C. She has been asked to be a contributor to the Fall 2011 Private Practice Sections, IMPACT MAGAZINE, and will be writing an article about service management in therapy, entitled If Disney Ran Your Practice.
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INTRODUCTION TO POLICY AND PROCEDURE MANUAL
MISSION STATEMENT - A Mission Statement stands as a concise representation of your guiding principles and what you want to accomplish including but not limited to your overall purpose, level of service, professionalism, accessibility and benefits of service as well as the mutual expectations of your patients, staff and yourself. It is helpful to keep you focused, to attract quality clinical and non - clinical staff, and as a public relations tool. Your vision of how you intend to run your practice will be represented by this statement and the policies which will follow.Below is a template for the creation of a mission statement:
________________________________________ was formed to provide_________ therapy and other related services to patients with _____________________. ____________________ is committed to meeting the physical and psychological rehabilitation therapy needs of ________________________________________________________________________________________________________. ________________________________ strives to achieve excellence in _________________________________________therapeutic service provision through a consistent demonstrated concern, competence and caring for the needs of our clients and their families. We accomplish this by providing superior quality of care with dedication, commitment and enthusiasm in a cost effective manner.
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Although the P/P Manual will focus on the overall procedural make up of your practice it is good to have a initial information sheet that highlights the basics of the day to day operation. For example:
SERVICE PROVISION:A. HOW TO INITIATE A REFERRAL:Our office is located at: _______________________________ and is easily accessible via _________________________. Our office can be reached Monday through Friday from 8:30-4:30 P.M. at ____________________________Intake information can also be faxed to ________________________ , or emailed to _________________________. Confirmation of any referral left after normal business hours will be made the next business day.
B. PERFORMANCE OF INDIVIDUALIZED THERAPY SERVICES ______Therapy sessions will be performed by providers who are licensed in _______
state. All licenses will be verified with the Office of the Inspector General prior to the start of care.
All therapists will be required to go through a thorough screening and an orientation process to both policy and procedures prior to beginning services.
Prior to beginning services the therapist will review a copy of the physician’s prescription; if a therapist thinks that the frequency and duration should be modified in order to better meet the patients need, a written request and explanation will be sent to the physician.
C. SUPERVISION OF SERVICES Monthly Supervision – Once monthly each therapist will have a mandatory
meeting with the administrator to review caseloads and discuss any specific concerns about therapy or treatment. Annual Performance Assessment – Every therapist will be evaluated for competency on an annual basis. Covered during the onsite competency review are treatment and procedures techniques , safety factors, teaching, guidance and counseling .
Chart Review – On a quarterly basis, charts of all active patients currently on program will be reviewed for contents, clarity, and proper medical documentation .
REVIEW OF THE POLICY AND PROCEDURE MANUAL
Your policy and procedure manual has to be considered a “living, breathing document”, not something to be taken down and dusted on a yearly basis. Make sure that on your introduction page, you document the date of the origin of the manual. The policy and procedure manual should be reviewed yearly and updated as often as necessary to reflect current standards of practice, new regulations, changes in state and federal law, along with any requirements of contracts you may
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enter into. It is not necessary to do this all at once, and often it is a good idea to stagger the review so that it does not become an overwhelming task. At the bottom of each and every page, indicate the initial date of the creation of the form, and then add subsequent dates of review. If no changes are warranted that should be indicated as well.Example: 9/05/09, R 10/01/09 NC, on the bottom of the form would indicate the initial date of the form or policy as 9/05/09 with a R on 10/01/09 resulting in no change. Had a change been made you can indicate it as:9/5/09, R10/01/09 Rev.
SECTION ONE: FORMS FOR DIRECT PATIENT CARE
I think it is always helpful to keep a copy of all the forms you use in the direct care of patients in a central location of your policy and procedure manual. The makes it easier to orient new clinical and non - clinical staff members. You can also indicate on the boiler plate form any time you have reviewed or revised the form with a connotation on the bottom. There are endless number of direct patients forms - the following are a few common ones.
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INITIAL INTAKE FORM - Generic for Adults
Date of Referral: _______________
Name of Patient: ____________________________________ GENDER: ___ DOB: ___/___/____
Referred By : _________________________
Date of accident / onset of injury/disease: __________Address: _____________________________________________________________________________Telephone No ____________________________ Contact Person _____________________________Primary Diagnosis and Presenting Conditions:
_____________________________________________________________________________ Reason For Referral/ Treatment Prescription (Frequency and Duration)
_______________________________________________________________________Equipment Currently Used: _________________________________________________________________Name / Address/ Tel. of Physician:
Social Security Number: __________________________________________
NAME OF CARRIER: _____________________________________________ADDRESS:__________________________________________________________________________________________________________________________________________________________________
Claim / Group or Authorization # ______________________________________________________________________________________
Name of Insured if Other than Patient: _______________________________________________________
Assignment of Benefits Required? ____________________________________________________________
Terms/ Limits of Policy? ___________________________________________________________________Authorization for Treatment Required?
GENERAL HEALTH HISTORYDescribe your pregnancy, labor, delivery__________________________________________________________________________________________________________Was your child � Full term � Premature Gestational Age _____Birth weight _______Has your child ever been hospitalized? _______________________________________Was your child � Breast fed � Bottle fed? Did child transition easily to solids_________At what age did your child: Sit ______Crawl ____Walk ___Talk________________________________________________________________________________________Who lives at home ____________Siblings ________Any developmental issues or illnesses in family ______________________________________________________________Has your child ever been treated for?� Asthma � Allergies � Ear infections � Feeding Problems � Food hypersensitivities � Gastrointestinal Problems � Headaches � Major illness or injury � Seizures � Sensory or motor issues � Sleep Problems � Other__________________________Comments_____________________________________________________________________________________________________________________________________________________________________________________________________Has your child seen any of the following specialists?� Developmental Pediatrician � Neurologist � Psychiatrist � Audiologist� Occupational Therapist � Physical Therapist � Speech and Language Therapist� Neuropsychologist � Osteopath � Chiropractor � Homeopath � Nutritionist
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� Psychotherapist � Special Educator____________________________________________________________________
Areas of concern__________________________________________________________ ____________________________________________________________________
Please Note: Your health information will be kept confidential. Any information that we collect about you on this form will be kept confidential in our office.
_______________________ __________________ ____________________Name of Parent/Legal Guardian Signature Date
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PHYSICAL THERAPY INITIAL EVALUATION Date of Visit: ____________
Name of Patient: ____________________________________ Referred By : _________________________Primary Diagnosis and Presenting Conditions:
_____________________________________________________________________________________ Mental Status including safety awareness, judgment, motivation:
_____________________________________________________________________________________ Home Environment: _______________________________________________________________________Pre-morbid status:_______________________________________________________________________Equipment Currently Used: _________________________________________________________________VITAL SIGNS: B/P _______ P_________ R _________ GENDER: ___M ___ F DOB: ___/___/____
MUSCULOSKELETAL STATUS and FUNCTIONAL STATUS
Additional Comments: __________RANGE OF MOTION MUSCLE STRENGTH TONE/SYNEGRY
Treatment Recommendations ( Include frequency and goals): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Name of Patient: ____________________________________ Referred By : _________________________Primary Diagnosis and Presenting Conditions:
_____________________________________________________________________________ Mental Status including safety awareness, judgment, motivation:
_____________________________________________________________________________ Home Environment: _______________________________________________________________________Pre-morbid status including vocation:
__________________________________________________________Equipment Currently Used: _________________________________________________________________GENDER: ___M ___ F DOB: ___/___/____MUSCULOSKELETAL STATUS and FUNCTIONAL STATUS
Treatment Recommendations ( Include frequency and goals): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
FORM RE-EVALUATION PROGRESS REPORT Date of Visit: ______________30 Day Re-evaluation/ Summary ___60 Day Re-evaluation/Summary ___Physical Therapy ___Speech Therapy ___Occupational Therapy
Name of Patient: ____________________________________
Assessment: Summary of Present Status of Patient __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Response to Treatment: Summary of Response to Treatment Program: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Name of Patient: ____________________________________ Dates on Program: _____________ to ______________
1. Patient’s Status at Start of Program: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Vital Signs: BP______ P ___________ R__________
2. Patient’s Present Condition and Progress to Date: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. Scope of Services Provided and Outcome: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
4. Reason For Termination: ______________________________________________________________________________________________________________________________________________
5. Recommendations for Follow-Up Care (include how unmet goals will be addressed if applicable):
Child’s Name: _________________________________________ Date of Birth:
Chronological Age:Date of Evaluation:Name of Evaluator:Language of Evaluation:
Place of Evaluation: Standardized Tests or Evaluation Tools Used
A. Background Information:Parent/Guardian:Informant:Referral Source:Reason for Referral:Resides with: (include other children’s ages)Description of Problem: (General description according to informant)
B. Pre-natal – Birth – Medical History:Pre-natal History:Length of Pregnancy:Type of Delivery:Birth Weight:Medical History:
C. Developmental Milestones:
Crawling: monthsRolling: months
Sitting: monthsStanding: months
Cruising: monthsWalking: months
E. General Observations:
Child separated without/with difficulty from parent/caregiverChild maintained consistent/did not maintain consistent eye-contact throughout entire evaluation.
Behavior appeared:a) impulsiveb) distractiblec) shyd) withdrawn e) has good endurance
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F. Physical Status:i) Active Range of Motion (child moving their arms, legs, head)
Instead of writing “WNL” or “WFL”, you may write “movement in arms, legs, … show no limitation that would impede the child’s ability to do functional activities…”.
ii) Passive Range of Motion (therapist moving child’s, arms, legs,…)iii) Muscle Strength (Do not use muscle grades i.e., F, F+, G, G+) State in
functional terms, i.e., “child has enough muscle strength in hips and legs in order to lift leg up for walking, dressing climbing stairs…”.
iv) Muscle Tone : Do not use words like hyper or hypotonicity. You can say child has increased tone or decreased tone or a combination of tone. You must then explain if the status of their tone will affect function.
v) Note any difference between right and left side of body
Other Neuromuscular Assessments:Reflexes:Reactions:
G. Gross Motor Skills :
- Can child lift head up while face on stomach- Can child roll from stomach to back- Can child go from his/her back to a sitting position(Do not use works like “supine”, “prone”, “contact guarding”, “mod. assist”, …etc).Note ability to move from one position to another (ie. –sit to stand, crawl to sit)Gait (child’s pattern of walking)
If you must use a technical term to describe a child’s gait, please briefly explain. For Gait – describe whether it is functional and safe for ADL
H. Fine Motor Skills :- Can child pick up large and small objects- Can child manipulate ADL tools like spoon, washcloth, comb…etc- If you must use words like neat pincer grasp, superior pincer, you must show how
these grasp patterns affect function.
I. Sensory Motor :If you find a child has gravitational insecurities, poor body awareness, tactile defensiveness, you must show how it affects the child’s function. J. ADL : (include any feeding concerns)
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Make mention of balance ability in functional tasks. Make note of child’s endurance for functional activities and if respiration during activities appears within functional limits
K. Summary : Child is a ____ year old child who presently demonstrates the following:
a) strengths
b) weaknesses
L. Recommendations:
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PEDIATRIC OCCUPATIONAL THERAPY EVALUATION
Child’s Name:Date of Birth:Chronological Age:Date of Evaluation:Name of Evaluator:Language of Evaluation:
Place of Evaluation: Standardized Tests or Evaluation Tools Used
A. Background Information:Parent/Guardian:Informant:
Referral Source:Reason for Referral:Resides with: (include other children’s ages)Description of Problem: (General description according to informant)
B. Pre-natal – Birth – Medical History:Pre-natal History:Length of Pregnancy:Type of Delivery:Birth Weight:Medical History:
C. Developmental Milestones:
Crawling: months Does child: Suck his/her thumb? Yes NoSitting: months
Rolling: months Use a pacifier? Yes No
Standing: months Drink from a bottle? Yes NoWalking: months Drink from a cup? Yes No
Eat chewable food? Yes No
E. General Observations:Child separated without/with difficulty from parent/caregiverChild maintained consistent/did not maintain consistent eye-contact throughout entire evaluation.
Behavior appeared:- impulsive- distractible- shy
- withdrawn - has good endurance
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F. Physical Status:vi) Active Range of Motion (child moving their arms, legs, head)
Instead of writing “WNL” or “WFL”, you may write “movement in arms, legs, … show no limitation that would impede the child’s ability to do functional activities…”.
vii) Passive Range of Motion (therapist moving child’s, arms, legs,…)viii) Muscle Strength (Do not use muscle grades i.e., F, F+, G, G+) State in
functional terms, i.e., “child has enough muscle strength in hips and legs in order to lift leg up for walking, dressing climbing stairs…”.
ix) Muscle Tone : Do not use words like hyper or hypotonicity. You can say child has increased tone or decreased tone or a combination of tone. You must then explain if the status of their tone will affect function.
x) Note any difference between left and right side of body
Other Neuromuscular Assessments:Reflexes:Reactions:
M. Gross Motor Skills :
- Can child lift head up while face on stomach- Can child roll from stomach to back- Can child go from his/her back to a sitting position- How would you describe the movements of transition from one position to
another- How is balance during movement
Gait (child’s pattern of walking)If you must use a technical term to describe a child’s gait, please briefly explain.Is gait functional and safe for daily activities
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N. Fine Motor Skills :- Can child pick up large and small objects- Can child manipulate ADL tools like spoon, washcloth, comb…etc- If you must use words like neat pincer grasp, superior pincer, you must show how
these grasp patterns affect function.- Can child bring hand across body, bring hand to mouth- Does child show a preference for hand use (emerging hand dominance)O. Sensory Motor and Cognitive Abilties If you find a child has gravitational insecurities, poor body awareness, tactile defensiveness, you must show how it affects the child’s function.Can child following simple directions?Can child imitate behavior?Does child show ability to use common household items like a spoon or comb
P. ADL : (include any feeding concerns)
Q. Summary : Child is a ____ year old child who presently demonstrates the following:
a) strengths
b) weaknesses
R. Recommendations:
PEDIATRIC SPEECH AND LANGUAGE EVALUATION
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Child’s Name:Date of Birth:Chronological Age:Date of Evaluation:Name of Evaluator:Language of Evaluation:
Place of Evaluation: Standardized Tests or Evaluation Tools Used
A. Background Information:Parent/Guardian:Informant:Reliable:Reason for Referral:Resides with: (include other children’s ages)Description of Problem: (General description according to informant)Familial history of speech, language, hearing, emotional or learning problem
B. Pre-natal – Birth – Medical History:Pre-natal History:Length of Pregnancy:Type of Delivery:Birth Weight:Medical History:Ear Infections:Audiological assessment: - Location
- Date:- Results:
C. Developmental Milestones:
Crawling: months Does child: Suck his/her thumb? Yes NoSitting: months Use a pacifier? Yes NoStanding: months Drink from a bottle? Yes NoWalking: months Drink from a cup? Yes NoFirst Words: months Eat chewable food? Yes NoPhrases: months
D. Behavioral/Social History : (As reported by informant)
E. Bilingual/Bicultural Background (bilingual only)
F. Direct Examination : (Include strengths and weaknesses in all areas)
G. Behavioral Observations : (As observed by the evaluator)
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H. Play Development :
I. Peripheral Speech Mechanism : (Include any feeding concerns)
J. Speech :o Articulation : (Include phonological analysis and statement on speech
intelligibility)o Voice :o Prosody/Fluency:
K. Formal Testing :Test Administered: The Rosseti Infant Toddler Language Scale:Receptive Language: Expressive Language:Basal Level: months Basal Level: monthsCeiling Level: months Ceiling Level: months
L. Receptive Language: (Include strengths and weaknesses)
M. Expressive Language: (Include strengths and weaknesses. If child is verbal, write a language sample and analysis. If child is non-verbal, include a detailed explanation of non-verbal communication mode.)
N. Impression : (Include developmental levels for all tested areas)
I consent and give permission to you and those acting under your authority to photograph/video and use the likeness of my _________ in connection with ____________________
By signing below I certify that I am the (please check) ___ parent or ___ legal guardian of the child above, a minor. I release ___________________, its parent, affiliates, officers, directors, agents and employees, and those acting under its authority, from all debts, claims and liabilities of any kind arising out of or in connection with the use and publication of the photograph/ likeness referred to above. The undersigned does hereby agree to hold _____________________, its parent, affiliates, officers, directors, agents, and employees, and those acting under its authority, against loss from any claim, action, or demand that may be brought at any time by the above-named minor or by anyone acting on the minor's behalf for the purpose of enforcing a claim for damages on account of the use and publication of the minor's likeness and photograph. This permission is for use of ________________________ only.
________________________________________________Signature Date
________________________________________________Witness Date
Agreement and Waiver for participation in onsite classes
I __________________the parent or guardian of _________________(Thereafter referred to as "my child") give permission for my child to participate in the NAME OF YOUR PRACTICE classes to be held once weekly on _________ from ____ to _____ for a ______ week period beginning ______. The cost of the program is ___________, payable in advance to name of practice. I understand that I or a designated caretaker am responsible for being an active participant and supervising my child for the entire duration of each session. Should my child have to drop out of the program, _______________ agrees to reimburse the family for the program on a pro-rated basis. There are no refunds for any missed sessions, and no make up sessions are provided. I hereby release ____________ its principal owners, therapists, employees and representatives and all other individuals or organizations acting on behalf of ____________in connection with this program from any and all claims which I or my child may have arising from, resulting from or in connection with my child's participation in the ____________ program, including but without limitation, any claim, demands or causes of action for injuries to my child, including but not limited to injuries resulting from the use of any play equipment during the program. This agreement is signed for the purpose of fully and completely releasing, discharging and indemnifying ____________ its principal owners, therapists, employees, representatives, and all other individuals or organizations acting on behalf of _____________in connection with this program from all liability as herein described. Liability for the cancellation of the group by _____________is limited to the program fee.
Signed:
___________________________________ ______________Parent or Guardian Date
Acknowledged By:
___________________________________ _____________NAME OF PRACTICE Date
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PERMISSION SLIP FOR CAREGIVERS
Child’s Name: ______________________
I, ______________________ parent/legal guardian of the above named child hereby give permission for ___________________, a designated caregiver tosign on my behalf, any and all service verification forms for Early Intervention or Dept of Education, that need to be signed in the event that I am not available.
OR
I also give permission for ________________________to pick up my child from_____________________ when his therapy is finished. In the event that another person will pick up my child, I will notify this office.
_______________________Parent/Legal Guardian Name
_______________________ _______________Signature Date
I _______________________ understand that my insurance company will be sent an itemized bill for each session in accordance to reasonable and customary charges. I agree to assign benefits directly to ______________________for all therapy services rendered. I also agree to remit any monies sent to me in error from my insurance company for services rendered to ______________________. I agree to pay for all services rendered should my insurance company deny payment for services rendered, and will be responsible for any deductible, co-insurance or co-payment, to be paid at the time of my visit.
XXXXXXXXXXXXXXXXX
For patients who pay privately or have out-of-network benefits, payments are due at the time of your visit. The fee for service for an initial evaluation is __________. The fee for service for all follow-up visits is _______. If requested, _____________________ will assist you in submitting claims to your insurance company.
CANCELLATION and DISCONTINUANCE FROM SERVICES POLICYThis office requires 24 hours notice for cancellations. Otherwise, you will be charged the full fee of the session. In addition, you will be charged the full fee for the session if you do not show for a confirmed appointment. Should you miss three consecutive visits it will be considered that you are not in adherence or compliance with your plan of care, and will be discharged from this office. Your primary physician will be notified and you will be given the names of three like professionals for your future use should you decide to begin therapy services again.
I have read and agreed to the above policies and procedures.
Patient or Responsible Party Signature___________________________ Date_____________
**** Make two copies of this form: one for your records and one for the patient
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PATIENT NOTIFICATION OF BILLING/CANCELLATION PROCEDURES
Charges for services that are provided by __________________ are based upon the procedures that are deemed necessary by the therapist and physician to enable the patient to reach their goals. The patient is responsible for the payment of all fees regardless of whether the patient has insurance coverage for all or part of the bill. If the patient does have insurance that will pay for a portion or all of the service, _____________________will bill the insurance company with the understanding that the patient provides all the necessary information, including but not limited to, a claim number, insurance card and a signed insurance form.
FEES and EXPENSES
1. Initial Evaluation - The charge for this is calculated on an hourly rate; rates can be pro-rated should an evaluation last longer than one hour.
2. Time sensitive direct therapy services – These can include such services as therapeutic exercise, massage, traction, kinetic exercises and activities. Charges for these services are based on one to one treatment time and are billed in 15 minute increments.
3. Modalities – This can include but not be limited to ultrasound, hot packs, electric stimulation, cold packs etc. There are separate charges for these services which may be performed by the primary therapist and in some instances a therapy aide or assistant.
Fees are reviewed on an annual basis, and _______________ reserves the right to adjust the fees when it is deemed necessary. Thirty day advance written notification will be provided if any fee increase is instituted.
BILLING FOR SERVICES RENDERED
All bills for services rendered will be sent out to the insurance carrier within thirty days of the service performed. Any co-payment, co-insurance, or deductible is due at the time of service. For patients paying out of pocket, payment is expected at the time of service unless other arrangements have been made. All invoices unpaid after 45 days will be subject to the maximum interest penalty/finance charge allowed by law. The ____________________reserves the right to cancel treatment if payment for services is not received, and to use whatever means necessary including an attorney, small claims court, or collection agency in an attempt to secure payment.
______________________________________________Signature of patient
____________ Date:
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Financial Policy
Patient’s Name (Please Print) ____________________________________ DOB ___/___/____
□Accept Assignment _______________ □Not Accept Assignment _______________ □Medicare □Self-PayWe are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies. Payment is due at the time of service unless arrangements have been made in advance. We accept Visa, MasterCard, American Express, Discover, debit cards, cash and checks. The patient is obligated to pay for late cancellation fee/no show fee/fee for arriving late/ non-sufficient funds fee, and these particular fees cannot be billed to any insurance companies.
Not all insurance plans cover all services. In the event your insurance plan determines a service “not to be covered,” you will be responsible for those charges. Please be aware that some insurance companies have a maximum number of visits that you are allowed; some companies also require prior-authorizations. It is the patients’ responsibility to know their ________ therapy benefits, check with their insurer if the prior-authorization is required and to follow up with our office if it was obtained & visits were approved.
Accept Assignment Patients: We have made prior arrangements with some insurance companies to accept an assignment of benefits. As a service to you, we will file your insurance claim if you assign the benefits to Beyond Basics – in other words, you agree to have your insurance company pay us directly.
I agree to make immediate co-insurance and deductible payment upon receipt of services rendered. If ____________ doesn’t get reimbursed from my insurance company within 30 days from date of service, I will be financially responsible for the full remaining balance. If my insurance issues me the checks because Beyond Basics is an out-of-network provider, I am responsible to assign them to _________________. If my insurance company determines that my visits are (were) not medically necessary, I am responsible to pay the full fee for my treatments.
Not Accept Assignment Patients: If you are insured by a plan that we do not have prior arrangement with, we will prepare and send the claim for you in an unassigned basis. This means the insurer will send the payment directly to you. Therefore, our charges for your care are due in full at the time of service.
I agree to make immediate payment upon receipt of services rendered. I understand that my insurance forms will be submitted electronically/mailed from ____________________ so that I may get reimbursed. I also have the option of mailing out the insurance forms myself so that I may get reimbursed. It is also my responsibility to follow up on my reimbursements with my insurance company.
Private Patients: Payment is expected at the time of service. Upon request, we will give you a paid bill to submit to your insurance company so that you can attempt to get reimbursed in part or in full. With your permission, we will cooperate fully with your insurance company if they request copies of treatment notes or other information related to the processing of your claim. Please note that we cannot make any representation that your insurance company will reimburse you in part or in full for our services, and payment to us in full is required regardless of the final determination of coverage by your carrier.
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Cancellation Fee (less than 24 hours) $No Show Fee $Non-Sufficient Funds Fee $Canceled/Stopped Check Fee $Late fee (for each 15 minutes) $
IF ANY PAYMENTS ARE OVERDUE BY 60 DAYS, UNCOLLECTED FUNDS WILL BE SENT TO OUR COLLECTION AGENCY AND COLLECTION /PROCESSING/ATTORNEY/COURT FEES WILL BE ADDED. ALL INVOICES SHOULD BE DUE AND PAYABLE TO BEYOND BASICS PHYSICAL THERAPY, LLC WITHIN 30 CALENDAR DAYS. PATIENTS WILL BE RESPONSIBLE TO PAY 10 % LATE FEE OF A MONTHLY INVOICE AMOUNT. I HAVE READ AND UNDERSTOOD ____________________ FINANCIAL POLICY AND I AGREE TO BE BOUND BY ITS TERMS. I ALSO UNDERSTAND THAT SUCH TERMS MAY BE AMENDED BY THE PRACTICE FROM TIME TO TIME.Patient /Guardian Signature ____________________________ Date
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL HIV-RELATED INFORMATION :
Confidential HIV-related information is any information indicating that a person had an HIV-related test, or has HIV infection, HIV related illness or AIDS, or any information which could indicate that a person has been potentially exposed to HIV.
Under ___________ State Law, except for certain people, confidential HIV-related information can only be given to persons you allow to have it by signing a release. You can ask for a list of people who can be given confidential HIV-related information without a release form.
If you sign this form, HIV-related information can be given to the people listed on the form, and for the reason(s) listed on the form. You do not have to sign the form, and you can change your mind at any time.
If you experience discrimination because of release of HIV-related information, you may contact the ______ State Division of Human Rights at __________. These agencies are responsible for protecting your rights.
Name and address of facility/provider obtaining release:
Name of person whose HIV-related information will be released:
Name and address of person signing this form (if other than above):
Relationship to person whose HIV information will be released:Name and address of person who will be given HIV-related information:
Reason for release of HIV-related information:
Time during which release is authorized:
From: To:
My questions about this form have been answered. I know that I do not have to allow release of HIV-related information, and that I can change my mind at any time.
___________________________ _____________ Signature Date
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Please note: The next two forms are needed for HIPAA compliance. Each patient must receive and keep a NOTICE OF PATIENT PRIVACY PRACTICES; on that form you need to fill in the name of your practice and fill out the name of address of your HIPAA compliance officer at the bottom. YOU can be listed as the compliance officer. Make two copies of the PATIENT INFORMATION CONSENT FORM, so that both you and your patient have a signed copy.
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NOTICE OF PATIENT PRIVACY PRACTICES
According to the Health Insurance Portability and Accountability Act, known as HIPAA, physical, occupational and speech therapists in private practices must incorporate the federal privacy standards to protect patient’s medical records and other health information provided to health plans, doctors, hospitals and other health care providers. Please note that your personal health information may be used by _______________ for treatment, obtaining payment, during an audit, in emergencies, or when required by law. You will be asked for written authorization to use their personal medical information for any other reason than those listed above. You have the right to review their personal health information at any time, to request that inaccurate information be corrected, or to request a list of instances when the information has been disclosed for reasons other than treatment, payment or other administrative purposes. You have the right to restrict how the information is used and disclosed for treatment, payment and administrative operations. The requests for restrictions will be considered on a case-by-case basis. You have the right to address concerns and complaints about a potential violation of their health privacy to the US Department of Health and Human Services.
For further questions, you may contact the Compliance Officer, (list name and address).
( Solo practitioners can be Compliance Officer for their practice).
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PATIENT INFORMATION CONSENT FORM
I have read and understand this practice’s Notice of Patient Information Practices. I understand that the company may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the company. I also understand that the Company will consider requests for restrictions on a case by case basis, but does not have to agree to requests for restrictions.
I hereby consent to the use and disclosure of my personal health information for purposes as noted in the Company’s Notice of Patient Information Practices. In doing so, I hereby release ________________________________________________________________________________________________________________________________________ from any and all legal liability that may arise from the release of such information. I agree that a copy of this authorization may be used in place of the original.
I understand that I retain the right to revoke this consent by notifying the Company in writing at any time except for that action which has already been taken. It shall be effective only long enough to answer the purpose of which it is given and no further confidential information will be released without the execution of an additional written authorization.
Patient and Parent/Guardian’s Printed Name if Patient is under 18
HIPAA Agreement for Cover Business EntityName of Covered Entity:
Name of Business Associate:
Obligations and Activities of Business Associate
a. Business Associate agrees to not use or disclose Protected Health Information other than as permitted or required by the Agreement or as Required By Law.
b. Business Associate agrees to use appropriate safeguards to prevent use or disclosure of the Protected Health Information other than as provided for by this Agreement.
c. Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to Business Associate of a use or disclosure of Protected Health Information by Business Associate in violation of the requirements of this Agreement. Business Associate agrees to report to Covered Entity any use or disclosure of the Protected Health Information not provided for by this Agreement of which it becomes aware.
d. Business Associate agrees to ensure that any agent, including a subcontractor, to whom it provides Protected Health Information received from, or created or received by Business Associate on behalf of Covered Entity agrees to the same restrictions and conditions that apply through this Agreement to Business Associate with respect to such information.
Business Associate agrees to make internal practices, books, and records, including policies and procedures and Protected Health Information, relating to the use and disclosure of Protected Health Information received from, or created or received by Business Associate on behalf of, Covered Entity available to the Covered Entity, or to the Secretary , in a time and manner or designated by the Secretary, for purposes of the Secretary determining Covered Entity's compliance with the Privacy Rule
e. Business Associate agrees to document such disclosures of Protected Health Information and information related to such disclosures as would be required for Covered Entity to respond to a request by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45 CFR � 164.528.
Permitted Uses and Disclosures by Business Associate
Except as otherwise limited in this Agreement, Business Associate may use or disclose Protected Health Information to perform functions, activities, or services for, or on behalf of, Covered Entity provided that such use or disclosure would not violate the Privacy Rule if done by Covered Entity or the minimum necessary policies and procedures of the Covered Entity.
a. Except as otherwise limited in this Agreement, Business Associate may use Protected Health Information for the proper management and administration of the Business Associate or to carry out the legal responsibilities of the Business Associate.
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b. Except as otherwise limited in this Agreement, Business Associate may disclose Protected Health Information for the proper management and administration of the Business Associate, provided that disclosures are Required By Law, or Business Associate obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential and used or further disclosed only as Required By Law or for the purpose for which it was disclosed to the person, and the person notifies the Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached.
c. Except as otherwise limited in this Agreement, Business Associate may use Protected Health Information to provide Data Aggregation services to Covered Entity as permitted by 45 CFR � 164.504(e)(2)(i)(B).
d. Business Associate may use Protected Health Information to report violations of law to appropriate Federal and State authorities, consistent with � 164.502(j)(1).
Obligations of Covered Entity
Provisions for Covered Entity to Inform Business Associate of Privacy Practices and Restrictions
Covered Entity shall notify Business Associate of any limitation(s) in its notice of privacy practices of Covered Entity in accordance with 45 CFR � 164.520, to the extent that such limitation may affect Business Associate's use or disclosure of Protected Health Information.
a. Covered Entity shall notify Business Associate of any changes in, or revocation of, permission by Individual to use or disclose Protected Health Information, to the extent that such changes may affect Business Associate's use or disclosure of Protected Health Information.
b. Covered Entity shall notify Business Associate of any restriction to the use or disclosure of Protected Health Information that Covered Entity has agreed to in accordance with 45 CFR � 164.522, to the extent that such restriction may affect Business Associate's use or disclosure of Protected Health Information.
Permissible Requests by Covered Entity
Covered Entity shall not request Business Associate to use or disclose Protected Health Information in any manner that would not be permissible under the Privacy Rule if done by Covered Entity except if the Business Associate will use or disclose protected health information for, and the contract includes provisions for, data aggregation or management and administrative activities of Business Associate
Term and Termination
a. Term. The Term of this Agreement shall be effective as of __________________ and shall terminate when all of the Protected Health Information provided by Covered Entity to Business Associate, or created or received by Business Associate on behalf of Covered Entity, is destroyed or returned to Covered Entity, or, if it is infeasible to return or destroy Protected Health Information, protections are extended to such information, in accordance with the termination provisions in this Section. Termination for Cause. Upon Covered Entity's knowledge of a material breach by Business Associate, Covered Entity shall either:
1. Provide an opportunity for Business Associate to cure the breach or end the violation and terminate this Agreement
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2. Immediately terminate this Agreement if Business Associate has breached a material term of this Agreement and cure is not possible; or
3. If neither termination nor cure are feasible, Covered Entity shall report the violation to the Secretary.
b. Effect of Termination. 1. Except as provided in paragraph (2) of this section, upon termination of this
Agreement, for any reason, Business Associate shall return or destroy all Protected Health Information received from Covered Entity, or created or received by Business Associate on behalf of Covered Entity. This provision shall apply to Protected Health Information that is in the possession of subcontractors or agents of Business Associate. Business Associate shall retain no copies of the Protected Health Information.
2. In the event that Business Associate determines that returning or destroying the Protected Health Information is infeasible, Business Associate shall provide to Covered Entity notification of the conditions that make return or destruction infeasible. Upon [Insert negotiated terms] that return or destruction of Protected Health Information is infeasible, Business Associate shall extend the protections of this Agreement to such Protected Health Information and limit further uses and disclosures of such Protected Health Information to those purposes that make the return or destruction infeasible, for so long as Business Associate maintains such Protected Health Information.
Miscellaneous
a. Regulatory References. A reference in this Agreement to a section in the Privacy Rule means the section as in effect or as amended.
b. Amendment. The Parties agree to take such action as is necessary to amend this Agreement from time to time as is necessary for Covered Entity to comply with the requirements of the Privacy Rule and the Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191.
c. Survival. The respective rights and obligations of Business Associate under Section [Insert Section Number Related to "Effect of Termination"] of this Agreement shall survive the termination of this Agreement.
d. Interpretation. Any ambiguity in this Agreement shall be resolved to permit Covered Entity to comply with the Privacy Rule.
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SAMPLE PATIENT SATISFACTION SURVEY
We would appreciate it if you would take a few minutes to complete this Patient Satisfaction Survey . This information will be utilized to evaluate and improve our services. Individual comments about your thoughts and concerns are greatly appreciated. Thank you for taking the time to complete this survey. You have the option of sharing the therapist’s name and your name.
QUESTIONS CIRCL
ONE
COMMENTS
1. During your telephone contacts with our “front” office, was the staff prompt, courteous, helpful and professional?
YES NONA
----------------------------
2. Was your initial evaluation and subsequent treatment sessions scheduled at a time that was convenient for you?
3. Were the findings of your evaluation and treatment plan explained to you in a satisfactory manner?
4. Do you feel like you consistently had adequate individual time with your therapist?
5. Did you think that the treatment you received and the outcome of your treatment met or exceeded your level of expectations?
6. Was your therapist available to answer any questions or concerns before, during or after treatment?7. Was the level of communication between our office and your
case manager and/or physician adequate?8. Would you consider recommending our services to others?9. Was the cleanliness, professionalism and confidentialityof the office to your satisfaction?10. Were all billing/insurance/reimbursement issues handled to
your satisfaction?11. Do you feel like your goals for participating in treatment have
been met?12. Overall, were you satisfied with our performance and service?
Additional Comments:
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_____ It is okay to use comments for promotional material
SAMPLE SATISFACTION SURVEY – REFERRAL SOURCES
We would appreciate it if you would take a few minutes to complete this Satisfaction Survey .
This information will be utilized to evaluate and improve our services. Individual comments
about your thoughts and concerns are greatly appreciated. Thank you for taking the time to complete this survey. You have the option of sharing your name.
QUESTIONS YES, NO, NA
COMMENTS
1. During your telephone contact with our “front” office, was our staff prompt, courteous, helpful and professional?
----------------------------
2. Was the client you referred contacted or scheduled for an evaluation within a reasonable time period?
3. Was the level of written and oral communication provided adequate and satisfactory?
4. Did our fees align positively with your expectations?
5. Did the length of treatment align positively with your level of expectation?
6. Did you think that the treatment your client received and the outcome of their treatment meet or exceeded your level of expectations?
7. Would you consider referring other patients to us?
8. Would you consider recommending our services to others?
9. Did our services meet your needs and the needs of your patients?
Additional Comments:
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___ It is okay to use comments for promotional material
ADVANCE BENEFICIARY NOTICE (ABN)NOTE: You need to make a choice about receiving these health care items or service
We expect that Medicare will not pay for the item(s) or service(s) that are described below. Medicare does not pay for all of your health care costs. Medicare only pays for covered items and services when Medicare rules are met. The fact that Medicare may not pay for a particular item or service does not mean that you should not receive it. There may be a good reason your doctor has recommended it. Right now, in your case, Medicare will probably not pay for:
Name of Service:
Because:
The purpose of this form is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you might have to pay for them yourself. Before you make a decision about your options, you should read this entire notice carefully.
� Ask us to explain, if you don’t understand why Medicare probably will not pay.� Ask us how much these services or items will cost (Estimated cost: $ ) in case you
have to pay for them yourself or through other insurance.PLEASE CHOOSE ONE OPTION. CHECK ONE OPTION. SIGN AND CHECK YOUR CHOICE.
_____OPTION 1. Yes. I want to receive these items or services. I understand that Medicare will not decide to pay unless I receive these items or services. Please submit my claim to Medicare. I understand that you may bill me for items or services and that I may have to pay the bill while Medicare is making a decision. If Medicare does pay,
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you will refund to me any payment that I made to you that are due to me. If Medicare denies payment, I agree to be personally responsible for payment. That is, I will pay personally either out of pocket or through any other insurance that I have. I understand that I can appeal Medicare’s decision.
______OPTION 2. NO. I have decided not to receive these items or services. I will not receive these items or services. I understand that you will not be able to submit a claim to Medicare and that I will not be able to appeal your opinion that Medicare won’t pay.
_____________ _____________________________________________Date Signature of patient or person acting on patient’s behalf
NOTE: Your health information will be kept confidential. Any information that we collect about you on this form will be kept confidential in our office. If your claim is submitted to Medicare, your Health information on this form may be shared with Medicare. Your health information which Medicare sees will be kept confidential by Medicare.
POLICY STATEMENT: REPORTING OF INCIDENTS Actual and potentially serious injuries to any patient will be reported immediately to the administrator of the practice. Documentation of all incidents shall be made on the Incident Report Form (see below) This can include falls, burns, complaints of alleged theft or damage to personal property belonging to patient.
I N C I D E N T R E P O R T F O R M
Patient’s Name:________________________________D.O.B:_______________ Date of Incident:________/_______/________ Time:_______AM/PM
Specific Location of Incident _______________________________Participants:Patient's Name:__________________________________________________________Clinician:________________________________________________________________Other :_______________________________________________________________________________________________________________________________________Other Witness(es) if any:Name of Witness:________________________ Contact Phone Number:___________________________
Description of Incident: (How did accident happen, where were participants at the time of the incident, what were participants doing, specify any equipment or tools used)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
[ ] Patient instructed to see Physician or go to emergency room
Name of Person Completing this report: _________________________________________Signature:_________________________________Title:____________________________Date:_____________________________________
Follow-up (as needed): (To be completed by Administration):______________________________________________________________________________________________________________________________________________________________________________________________Note: All incidents with injury to must be communicated immediately to the administrator
POLICY STATEMENT CHILD ABUSE
All suspected cases of child abuse/neglect (CA/N ) must be reported as per the guidelines outlined by the state in which you practice. This includes when you suspect that a child is abused or neglected or when a parent or caretaker makes a statement to you based on personal knowledge which if true would deem a child abused or neglected.Usually you can either call in the statement directly (you would then be considered the mandated reporter) or contact the designated person at the practice to call in the report ( you would then be the source of the report, and the designated person would be the reporter.Calls are made to the Central Register of Child Abuse and Neglect of your state. In order for the report to be accepted the child must be under 18 and live in your state. Included in the report:Name and address of child, their age and genderNature and extent of injuries, maltreatment, abuseChild’s behavior and conditionPerson responsible for injury, maltreatment, abuseSource of report
Usually, within 48 hours, a written report form must be sent in to your state’s Child Protective Services. Any photos, x-rays can be included in the report.The mandated reporter is immune from civil or criminal liability when the report is made in good faith. Without the written permission of the reporter, Child Protective Services must maintain confidentiality about the source of the report. Failure to report cases of suspected child abuse or neglect is a class A misdemeanor with criminal and civil sanctions possible.
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POLICY STATEMENT ON CONFIDENTIALITY AND RELEASE OF INFORMATION
Any and all patient related information received by this practice is considered confidential. This information is not discussed with anyone unless when necessary to coordinate services and care with other involved therapists, supervisors and management personnel. Any and all therapists, providers or staff member who have access to any type of patient information are oriented to this policy at the time of their hire and as often as necessary afterwards to ensure compliance.
Documentation regarding the clinical records as well as and billing is the property of the agency, and all information recorded is considered confidential. Access to the record either as a hard copy or computer data is limited to those directly providing care, management staff, quality assurance personnel, and representatives of accrediting or regulatory bodies. The release of a written copy of the record is authorized only when the administrator of this practice is satisfied that the request is authorized and approved by the patient or guardian or other legal body having the right of access. Staff/providers must first have the authorization of the administrator before making any copies of the clinical record.
Clinical records are kept in a locked and fire-proof file cabinet and may not be removed without permission. All records removed from the file cabinet during the day by authorized personnel must be returned by the end of the same calendar day.
Specific copies of documents may be provided to staff providing care, i.e., plan of care, physician orders, intake assessment when it has been deemed necessary. Personnel is responsible for the professional safeguarding of all such copies in their possession and destroying the copies when they are no longer needed.
At any time during regular office hours, the patient or authorized agent of the patient being treated may come to the practice and review or request for a copy of their clinical record.
In order to allow access to the record, a written release must be valid and signed by the patient or patient’s authorized agent.
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Any and all staff having access to any patient information are instructed in maintaining the confidentiality of such information during orientation and as often as necessary thereafter to ensure compliance with this policy. This includes but is not limited to the fact that:
1. No patient information may be released to any outside organization, individual or agency without a signed consent which authorizes release as previously stated.
2. They are to immediately inform the administrator of any request for patient information.
3. Great care must be taken to limit the discussion of patients while in public areas.4. No one should discuss one patient with another patient.5. They must be responsible to safeguard confidential information in their possession.6. Staff are cautioned that information shared with any vendors is limited to that
required for them to perform the service requested and authorized by the contract.
CONFIDENTIALITY AS IT RELATES t0 HIV-RELATED INFORMATION
This practice can receive confidential HIV related information needed to provide services to patients who are diagnosed as HIV positive. This will be limited to employees/therapists who:Have authorized access to patient care records, and reasonably need the information to
supervise, monitor, or administer a health services
Maintain or process patient care records for billing or reimbursement purposes.For others to be permitted to receive this information, a release form must be signed.
Access to HIV-Related Information:All office and staff will receive an initial in-service on this topic. All employees and providers
who are permitted access to the information will receive detailed in-service education initially and on an annual basis. The initial in-service will occur prior to employee’s access to the information.
There will be a general in-service explaining who may and who may not receive confidential HIV-related information. The detailed in-service will interpret the content of this policy, focusing on the legal prohibition against unauthorized disclosure and discuss the limits of the access allowed.
The following personnel will be allowed access to confidential HIV-related informationas knowledge is necessary to provide the appropriate care and treatment:Occupational Therapists – as it relates to the provision of skilled occupational therapyPhysical Therapists – as it relates to the provision of skilled physical therapy
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Speech and Language Pathologists – as it relates to the provision of skilled speech therapy
Social Workers – as it relates to the provision of service coordination-For the purpose of processing medical records and insurance claims:Intake Coordinator Clerk – to code ICD 9 CodesBilling Clerk – to verify insurance coverage and complete claim formFile Clerk – to file documentation into the medical record
Confidentiality and Disclosure:No person to whom confidential HIV-related information has been disclosed shall disclose the same information to another person except as authorized by the regulations .No person who obtained confidential HIV-related information may disclose or be compelled to disclosed such information, except to the following:The protected individual or a person authorized pursuant to law to consent to health care for
the individual.Any person to whom disclosure is authorized pursuant to a release.An employee or agent who has authorized access to patient care records.
- Any employee who needs the knowledge to provide appropriate care or treatment to the protected individual or child of the individual (See above statement regarding limitation of who may receive such information).
- Staff committees, accreditation, or oversight review organization may be authorized to access patient care records. In this instance those involved may only disclose confidential HIV-related information either back to the facility or provider, in order to carry out the monitoring, evaluation or service review for which it was obtained or to a federal, state or local government agency for the purposes of and subject to the condition of the regulations.
Non-Discrimination:No employee, agent, or contractor of the agency shall discriminate against any patient who has or is suspected of having AIDS, HIV Related Illness, or HIV Infection
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POLICY STATEMENTCONFIDENTIALITY STATEMENT: To be put on all emails and faxes generated from this
practice
This message is intended only for the addressee(s) and may contain information that is sensitive or confidential. If you have received this message in error, please notify the sender immediately and then delete the misdirected e-mail or destroy the misdirected fax. Thank you. Privacy Officer
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POLICY STATEMENT:
EMERGENCY PREPAREDNESS PLAN Emergencies and/or disasters are occurrences which can reasonably be expected to disrupt provision of services to our patients. Emergencies may include snow storms, power failures, hurricanes, transportation strikes etc. If an emergency or disaster situation occurred which would prevent a therapist from providing services, they would immediately contact our practice, and we would make every attempt to reach our patients. If there are any emergencies in the office that required immediate attention, we would immediately contact 911. All patients are required to give us an emergency contact on the initial intake form.A fire evacuation plan is posted in the administrative office in our practice.
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POLICY STATEMENTHEALTH AND SAFETY POLICIES AND PROCEDURES
I. INFECTION CONTROL:Infections are diseases that are caused by bacteria or viruses and are invisible to the human eye. Infections are spread when the organisms (bacteria and viruses) are carried from one site (or person) to another. Organisms can get onto our hands and be passed on to either ourselves or to another person that we touch with our hands. This makes hand-washing the most important way to prevent spreading infection. The organisms in our environment can be spread in different ways and do not always make us sick, however, we must always be alert to protect ourselves and our clients. The term “Universal Precautions” describes the methods we use to protect ourselves and our clients from these invisible germs and organisms.
1. In addition to blood and blood products, potentially infectious material means semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental products, and any body fluid that is visibly contaminated with blood and all potentially infectious materials in situations where it is difficult or impossible to differentiate between body fluids.
2. The following body fluids are not likely to transmit bloodborne infections, unless visible blood is present: feces, urine, nasal secretions, sputum, sweat, tears, vomit.
3. Saliva - The potential to spread HBV or HIV through saliva is believed to be remote.Universal Precautions are not necessary when contacting saliva outside the mouth (e.g., wiping drool, feeding patients).Universal Precautions are used in situations in which the fingers will have contact within the mouth (e.g., providing mouth care, oral stimulation, oral examination).
4. Breast Milk – Universal Precautions are not necessary in the home care setting for contact with breast milk.
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Occupational Exposure: Occupational exposure means reasonably anticipated skin, eye, mucous membrane or parentereal contact with blood or other potentially infectious materials that may result from the performance of duties.II. UNIVERSAL PRECAUTIONS:
Many infections are spread before it is know that they are present, or even before people show symptoms that they are sick. For that reason all health care workers MUST use universal precautions to protect themselves and their clients, and decrease the spread of infections.Universal Precautions include:Effective hand washing before and after contact with each client and after using the
bathroom anywhere. Wearing gloves does not stop the need for hand washing.Use of gloves with any “hands on” client contact where there may be contact with body
fluids.
Universal Precautions are effective and important tools used to prevent and control the spread of infection. When properly used, there should be no fear of spreading organisms from one client to another or from provider to family.Hand Washing: The most important thing that can be done to stop the transmission of infection is to thoroughly wash hands before and after any direct contact with a client. Proper technique is covered in orientation and annual in-service.Hands and other exposed skin surfaces are to be washed:
(a) before and after direct client contact. This includes before putting on gloves and after taking gloves off.
(b) immediately and thoroughly if inadvertently contaminated with blood or other potentially infectious materials.
Disposable Gloves: Disposable gloves are to be worn whenever there is a possibility of contact with client’s blood or other potentially infectious material, contact with mucous membranes, contact with non-intact skin, handling items or surfaces soiled with blood or other potentially infectious material. Disposable gloves are to be changed during procedures if they become torn or otherwise damaged. Gloves are to be disposed of after each use. They are not to be reused.
Health Care Providers/Employees with Exudative Lesions or Weeping Dermatitis:Health care providers/employees with exudative lesions or weeping dermatitis may not have direct client contact unless it has been medically determined that they can safely perform work activities. Providers/employees for whom it has been determined that they cannot safely perform work activities will refrain from direct client contact until the condition is resolved.
III. HAND WASHING PROCEDURE
Purpose: To assist in infection control by listing indication for hand washing. To provide knowledge of the steps to be taken to ensure thorough cleansing of hands. Hand washing to prevent the spread of infection must be practiced by ALL individuals in contact with clients. It is the responsibility of each person to protect themselves and others.
Indications for thorough hand washing using soap and water:Before and after every direct client contactBefore and after the removal of protective equipment
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Hand Washing Procedure:a) Remove all jewelry from hands. Use paper towel to turn on the faucet as well as to
obtain soap from container to prevent transfer of bacteria. Discard paper towel.b) Wet hands with water. Apply and spread a thin film of soap over the entire skin
surface. Wash thoroughly using continuous running water, with a rotary motion and friction. Avoid running water down elbows.
c) Do not touch the inside of the sink.d) Work soap into the ends of fingers and clean the nails.e) Rinse thoroughly and frequently under running water. f) Repeat steps “b” and “d” as often as needed.g) Dry hands by blotting with paper towel.h) Use paper towel to turn off the faucet.
IV. HEPATITUS B VIRUS:
Hepatitis B Virus (HBV) is a potentially life-threatening bloodborne pathogen. Center for Disease Control estimates there are approximately 280,000 infections each year.Approximately 8,700 health care workers each year contract Hepatitis B and about 200 will die as a result. In addition, some who contract HBV will become carriers, passing the disease on to others. Carriers also face a significantly higher risk for other liver ailments which can be fatal, including cirrhosis of the liver and primary liver cancer.HBV infection is transmitted through exposure to blood and other infectious body fluids and tissues. Anyone with occupational exposure to blood is at risk of contracting the infection.Employers must provide engineering controls; workers must use work practices and protective clothing and equipment to prevent exposure to potentially infectious materials. However, the best defense against Hepatitis B virus is vaccination.
Who needs the vaccination?The new OSHA Standard covering bloodborne pathogens requires employers to offer the three-injection vaccination series free to all employees who are exposed to blood or other potentially infectious materials as part of their job duties. This includes health care workers, emergency responders, morticians, first-aid personnel, law enforcement officers, correctional officers, correctional facilities staff, launders, as well as others.The vaccination must be offered within 10 days of initial assignment to a job where exposure to blood or other potential infectious materials can be “reasonably anticipated”. The requirements of vaccinations of those already on the job take effect July 6, 1992.
What does the vaccination involve?The Hepatitis B vaccination is a non-infectious, yeast-based vaccine given in three injections in the arm. It is prepared from recombinant yeast cultures, rather than human blood or plasma. Thus, there is no risk of contamination or developing HBV from the vaccine.
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POLICY STATEMENT
HIPAA CONFIDENTIALITY AGREEMENT AND TRAINING ATTESTATION
Please sign and return this form once you have read the four page training guide Please note: The following HIPAA CONFIDENTIALITY AGREEMENT AND TRAINING ATTESTATION can be used for clerical and clinical staff. Make two copies of the 4 page training booklet and signature sheet so that you can keep a copy of the staff member can keep a copy
HIPAA PROTOCAL AND PROCEDURES
Staff members affiliated with ___________________________________ have access to confidential information, both written and oral, in the course of their employment, affiliation and job responsibilities. It is imperative that this information not be disclosed to any unauthorized individuals to maintain the integrity of the patient information. An unauthorized individual would be any person that is not currently an employee of ____________________________________________ and/or any individual who is an employee of the company but has no business use for such information. Any other disclosures may only occur at the direction of the Privacy Officer ________________ or by patient authorization.
I have read and understand the company’s policy with regard to privacy and security of personal health information. I agree to maintain confidentiality of all information obtained in the course of my employment/affiliation including but not limited to, financial, technical, or proprietary information of the company and personal and sensitive information regarding patients, employees, independent contractors and vendors. I understand that inappropriate disclose or release of patient information is grounds for termination.
This practice is committed to maintaining the strictest privacy and confidentiality standards in the use and handling of any and all medical information we have access to. To improve the efficiency and effectiveness of the health care system, the Federal Government enacted an Administrative Simplification provision of a 1996 law that required Health and Hospital Services to adopt national standards for electronic health care transactions. At the same time, Congress recognized that the growth of the electronic technology sector could potentially seriously invade the privacy of health information. As a result for the first time, the government established Federal protections for individual health information which is effective April 14, 2003. This rule does not replace Federal, State or other laws that provide for even stricter privacy protection in some instances.The law is the Health Insurance Portability and Accountability Act, simply known as HIPAA. The part of the law that concerns us is the Privacy Rule. The Office of Civil Rights is charged with the responsibility for the Privacy Rule part of the law.Because information is so readily available by e-mail, fax, internet, electronic records it can easily be obtained by people that do not need tom know the information and could potentially misuse the information. HIPAA’s privacy rule addresses the following:
1. Greater Restrictions for the use and disclosure of personnel health information.2. Patients have more access to , and control and protection of their health information.3. Establishes appropriate safeguards that healthcare providers must achieve to protect the privacy of health information4. Holds violators accountable with criminal and civil penalties that can be imposed if they violate patient’s privacy rights.5. Balances public responsibility to disclose some forms of data to protect public health
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All employees of this practice are considered a “covered” entity, that is a person or organization that has access to protected health information and shares that information electronically. As such they are required to follow the HIPAA Privacy Rule. Each employee is given in-service training specifically about what is considered Protected Health Information (PHI), Rules for the Use and Disclosure of PHI, Guidelines to Protect the Privacy of Health Information: How To Protect Patient Privacy, What to do if You think someone’s privacy rights have been violated, and what the consequences are for breaking the rules. Each patient on program is presented with a Notice of Privacy Practices .
As an employee of _____________you are what is considered a “covered” entity, that is a person or organization that has access to protected health information and shares that information electronically. As such you are required to follow the HIPAA Privacy Rule.
Protected Health Information (PHI)
You need to know what information is covered under the rule and the types of information you are legally able to access and use. One common term is individually identifiable health information and protected health information or simply PHI. Both phrases are essentially the same and refer to health information or patient/client information that the patient/client shares with a health care entity.
Some information may not be considered PHI alone, but with other information it may be like pieces to a puzzle that could lead to the identification of patient/client. For example, a zip code is not normally a piece of information that can identify a patient, but together with a Medicare card and a telephone number, it is possible to identify that person as a patient. If the information can reasonably be connected to the person’s identity, then it is considered PHI in that instance.
All health information that identifies an individual is considered PHI. It doe not matter if we are responsible for creating the information or we receive it from another source such as a hospital, nursing home or DME company. Under the HIPAA law, it is treated the same, as confidential information. PHI can be oral, written or electronic information. A simple conversation between a nurse and an aide about a patient/client and the diagnosis is considered the same as written information or electronically communicated PHI.
In general, ask the questions “Do I need to know this information in order to do my job?” If the answer is no, then you should not access the information. You have authorization to access and use certain types of information as a “need to know” under particular circumstances, and conditions. Prior approval is required to have access to any other patient information.
Rules for the Use and Disclosure of PHI
To use PHI means to access, view, examine, analyze and share information. To disclose PHI means to release to, transfer to and or make information available to someone outside ARS. We use and disclose PHI for the following purposes:1. Treatment, payment, and healthcare operations without any additional consent.2. As authorized in writing by the patient.3. For disclosure to the individual patient
Routine and Non Routine Requests Not Related to Treatment
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If information is directly related to the job responsibilities that you must do, generally it can be disclosed. If the information is not within your job responsibility then you must go to the designated person responsible for requests and disclosures at your assigned facility and advise that individual of that request.
Guidelines to Protect the Privacy of Health Information: How You Can Protect Patient Privacy
There are many challenges to protecting patient health information because of the number of people, department, vendors, physicians and other professionals that may be directly or indirectly involved in a patient’s care. Here are some general guidelines and safeguards that would apply to any office, acute, sub-acute, home care or long term care situation:
1. Keep patient records in a designated area, refrain from leaving it accessible to unauthorized individuals, and protect it from the casual observer to view.2. Refrain from discussing any and all patient information in any public places, and make sure all formal and information patient conferences are held in areas that have limited access to unauthorized individuals.3. Remember to log off computer terminals so that confidential information cannot be viewed by on lookers.4. Refrain from leaving papers around; all reports should be filed immediately upon creation or receipt as appropriate.5. Utilize designated fax or copier machines for faxing or copying patient information. If no machine is specifically designated, fax or copy information in an area that has limited or no access to unauthorized individuals.
Authorization Because the law says it is appropriate for you to access and use information identified by the hospital leaders to complete your job responsibilities, written authorization is not required. Instances other than treatment, payment and health care operations that require access to patient information require a written authorization from the patient or authorized representative.
Privacy Officer
HIPAA requires each organization that uses protected health information to appoint a Privacy Officer to facilitate the implementation of these privacy rules. The Privacy Officer may designate a person to be responsible for implementing and maintaining most of these processes and the Privacy Officer retains oversight and responsibility for the entire program. It is your responsibility to know the names and contact numbers of the designated individuals that have been assigned responsibility for complaints and other requests related to patient privacy. The privacy officer for this practice is:
Notice of Privacy Practices
Each hospital, nursing home, private practice , HHA etc must have privacy practices designated to protect the privacy and confidentiality of patient protected health information. The Federal Government requires that each organization provides each patient a “Notice of Privacy Practice”. This is developed by the organization that defines policies as to how the organization may use and disclose patient personal health information. Privacy notices are distributed to patients only once and usually upon admission and upon request to any member of the public. Copies of the receipt for the Notice of Privacy Practices will be kept
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on file for a period of 6 years. Notice of Privacy Practice is given at the first time of the patient encounter. Parents have access to the files of their children under the age of 18.
Patient Privacy Rights
The patient also has the following rights regarding the use and disclosure of his or her protected health information without fear of retaliation. In addition, patients cannot be asked to waive their rights as a condition of treatment and payment.
1. A patient has the right to receive the Privacy Notice at the time of first service.2. A patient has the right to request restrictions or limitations on how their protected health information is used or disclosed for treatment, payment or healthcare operations. You may not grant or deny a patient’s request for restrictions. That request must be forwarded to the person responsible to approve or deny restrictions.3. Health care organizations will choose a method of identifying a record containing restricted information. A notation is made in the patient’s medical record indicating that restrictions to the use and/or disclosure of protected health information is in force. For example, a brightly colored sticker can be used to indicate there are restrictions contained in the medical record.4. The patient has the right to identify alternative means of communication and alternative locations that they wish to have their protected health information communicated for the purpose of maintaining confidentiality. This alternative method is different than the usual practice that the facility would use. This can include but not be limited to sending bills to a PO BOX as opposed to a home address, sending medical information via certified, not regular mail etc.
5. The patient has the right to request access to their health information for inspection and/or copying. This request is made in writing. Additionally, the patient may request to amend or change his or her health information by requesting to do so in writing.
6. The patient has the right to request in writing, an accounting of disclosures of health care information other than treatment, payment or health care operations.
Consequences for Breaking the Rules
There are penalties if you violate the HIPAA Privacy Rule intentionally. You can be subject to possible penalties by the Office of Civil Rights including civil and criminal penalties. Termination by this practice is also possible. Criminal penalties can include rather hefty monetary penalties and or jail time. Examples of criminal actions include knowingly releasing information in violation of the law, or selling the information. If you see someone breaking the rules intentionally, it is your duty to report violations to the administrator of this practice.
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REHABILITATION UPDATE/ DOCUMENTATION WHEN TREATING MEDICARE PATIENTS
The purpose of the rehab update is to review patient care and documentation by Occupational, physical and speech therapists. Upon acceptance of a referral, please perform and document the following:
1. Schedule new patient within 24 hours for an initial appointment.2. Perform a complete initial assessment and provide treatment during the first visit.3. Telephone physician if requested within 24 hours following initial evaluation to report:� initial evaluation date� brief assessment of problems identified� specific short term treatment goals� treatment frequency and duration� intended discharge date� request equipment if necessary� request other service evaluation if necessary4. Submit initial assessment if requested within five days of the visit. Documentation to
include:� established therapeutic treatment plan� short and long term goals
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� proposed frequency and duration
5. Telephone physician every two weeks to provide case conference update. If there is a change in the patient’s condition, call the physician during or following the visit. Call should include:
� visit dates� professional therapeutic intervention provided� goals achieved and new goals� treatment frequency and duration� intended discharge date� change in patient’s condition� request re-certification if visits to extend beyond initial re-certification period
6. Submit progress notes with five days of the visit describing:� professional therapeutic intervention provided to patient� patient’s response to treatment� documentation should be easy to read and understand � documentation should include weekly ROM and MS grades
7. Provide patient with written home program and/or education sheet8. Submit 60 day summaries including status of current goal and any new goals9. Document instruction and education of patient and/ care giver with level of
independence/ assistance needed and further instruction required.10. Submit discharge note when necessary11. Ensure that treatment plan is carried out as requested.
FORM: CLINICAL CHART REVIEW
Clinical chart reviews will be done on a quarterly basis to identify any deficiencies in the timeliness, accuracy, quality, and completeness of the chart.
Name of Patient ______________________________
Date Patient Started Program _____________________________
Name of Reviewer __________________________
1. Completeness of Enclosures of Appropriate Documents YES NO NA COMMENTS
A. Signed Physician Prescription
B. Initial Evaluation
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D. Signed Provider Monthly Report
E. Six Month Provider Progress Report
F. Discharge Summary
G. Signed Consent Form
1. Are all treatment notes legible and signed?
2. Are the dates of service listed in the monthly report in agreement with billing documents?
3. Are notes up to date, in order, with no break in sequence?
4. Is the documentation of the treatment rendered recorded in a clear and concise manner, and in accordance with the treatment plan?
POLICY STATEMENT ORIENTATION FOR STAFF THERAPISTS
Prior to beginning any new therapist is required to meet with the administrator of the practice review the mission and philosophy of the practice, the scope of services, administrative and personnel policies, job description, confidentiality, and safety issues. It is essential to assess each staff member’s capability to perform specified job responsibilities, and to familiarize new staff to his or her responsibilities. The practice want to ensure that staff demonstrate adequate knowledge and skills to competently deliver care to those children assigned to them as well as to provide ongoing in-service training, continuing education, and other opportunities to maintain and improve staff competence.The orientation process is coordinated and documented. Upon successful completion, the therapist and the Director sign and acknowledge completion and indicate if any immediate follow-up is warranted.Every therapist will be required to have a completed personnel folder on file which includes:Yearly Physical Exam and/or Doctor’s Note (updated yearly) Evidence of Mantoux (PPD) (updated yearly)List of Inservices attended Documentation of Rubella and Rubeola titer or immunization (date given and titer level)Two Professional Written References (See attachment)
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Health Assessment and Freedom from health ImpairmentIn-service Information on OSHA Bloodborne Pathogenes, Universal Precautions, Hepatitis B
Virus, and Infection Control, HIV Confidentiality, HIPAA Protocol and Procedures and Written Proof of Above (see Attachment)
Hepatitis B signed decline sheet or documented proof of vaccination Copy of SS card and current driver’s licenseProof of Citizenship – 1-9 and W -9 forms along with appropriate IDCopy of Tax ID form, business certificate, P.C. or Incorporation Papers if applicableResumeCurrent Liability InsuranceCurrent Professional License/RegistrationSigned and current Employment/or Independent Contractor Agreement
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FORM - REFERENCE LETTER Date: ______________
I, _____________________________________, hereby give permission to release (Print Name)information to ___________________________________________________________________concerning my performance and hereby unconditionally release your organization from all liability.
__________________________________ Applicant’s Signature ______________________ Social Security No.REFERENCE:Name: _________________________________ Phone#: ___________________Address: __________________________________________________________The above applicant has applied for a position with ____________________________.It would be appreciated if you would fill out the following information to the best of your ability in order to help us better evaluate his/her qualifications. Thank you for your cooperation.Confidential
ReportExcelle
nt
Good
Average
Poor Qualifying Statement
1. Adjustment to new situations
2. Practice
3. Judgment
4. Technical Skills
5. Interpersonal Skills
6. Teaching Skills
7. Leadership Skills
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Clinical Competency FormTreatment/Procedures Yes No NA CommentsPrinciples of asepsis /infection control appliedObservation/assessment made in accordance with patient’s needsReported any pertinent findings which needed immediate MD attentionDemonstrated good clinical skill and judgmentInformed Family/caregiver about ongoing therapy issuesRemained flexible during session adapting to patient’s needsTreatment provided in accordance with tx planSafety Factors Yes No NA CommentsHand washing done according to policyEquipment properly cared for and protectedHandling techniques performed in a safe
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mannerGuidance and Counseling
Yes No NA Comments
Used language appropriate for family/caregiverGave simple, easy to understand directionsInstructions followed logical sequenceAdditional Comments/Recommendations:
Therapist Signature:
Reviewer Signature:
FORM: EMPLOYEE ANNUAL HEALTH ASSESSMENT to be filled out by therapist
NAME: ________________________ DOB ________ POSITION: ________
HAVE YOU SUFFERED FROM ANY OF THE FOLLOWING IN THE LAST YEAR? YES/NO
COMMENTS1. High blood pressure 2. Heart trouble?
Heart trouble?
3. TB or persistent cough?
4. Bronchial asthma or hay fever?
5. Difficulty breathing?
6. Nervous breakdown?
7. Alcohol or drug abuse?
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8. Bone disease or arthritis
9. Epilepsy or dizzy spells?
10. Back injury?
11. Need glasses or eye problems?
12. Hearing or ear problems? 13. Are you pregnant? 14. Are you under the care
of a private physician?
15. Have you had chicken pox, herpes or shingles?
Known allergies __________________________________________________ _______________________________________________________________
Date of last physical examination________________________If you have had any major operations, list type and date _____________________
(THIS FORM IS TO BE COMPLETED BY THERAPIST) FREEDOM FROM HEALTH IMPAIRMENT
I attest that I am free from a health impairment which is a potential risk to the patient or which might interfere with the performance of my duties, including habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs that may alter my behavior.
I acknowledge that I am at risk of exposure or have been unknowingly exposed to the Hepatitis B virus as a result of my employment. It is my decision to:
________ refuse the Hepatitis B vaccine and hold harmless the practice. I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring the Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine. However, I decline the Hepatitis B vaccination at this time. I understand that by declining the vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, I continue to have occupational exposure to blood or other potentially infectious materials and want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series.
________ provide written proof of immunity (attach supportive documentation)________ provide written proof of previous vaccination (attach supportive
documentation)
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________ provide written proof of medical contraindication (attach supportive documentation)
_______________________________________ Date:_____________Supervisor or Witness
SAMPLE EMPLOYEE HANDBOOK
The purpose of the handbook is to inform every employee of _________________________ of the general policies and procedures as well as the personnel policies and regulations of this practice. These policies and procedures may be revised from time to time and you will be notified in writing of any changes.
1. ORGANIZATIONAL STRUCTURE
All employees are to report directly to the administrator of this practice.
2. CLASSIFICATION OF EMPLOYEES
a. Temporary – Employees hired for a short period of time or a temporary position within a given time period, in general, not to exceed 6 continuous months, regardless of the number of hours worked each day. A temporary employee cannot be considered for benefits.
b. Part-time without benefits – An employee working else than 17.5 hours, and not eligible for benefits.
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c. Part-time with benefits – An employee working 17.5 – 32 hours on a regularly scheduled basis and eligible for benefits.
d. Full time – An employee working 32-40 hours per week on a regularly scheduled basis and eligible for benefits.
Please note that _________________does not guarantee the number of hours an employee will be able to work on any given workweek. All employees regardless of classification are on probation for the first 90 days and are not eligible for benefits.
3. EQUAL EMPLOYMENT OPPORTUNITY POLICY
___________________ is committed to the policy that there will be no discrimination in the hire or tenure of employment of a qualified individual on the basis of factors prohibited by Federal or State Law such as race, religion, color sex, marital status, national origin, physical handicap or disability, or age. In addition _________________________ is committed to making sure that there is no sexual harassment in our premises. The EEOC defines sexual harassment as unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitute sexual harassment when: a) submission of such advances is either an explicit or implicit term or condition of employment b) submission or rejection of the advance affects the basis of employment decisions for the employee c) such conduct has the purpose or effect of interfering with the employee’s work performance or creates an intimidating, hostile or offensive working atmosphere.
Employees found to be harassing other employees will be immediately and appropriately disciplined, which may or may not include immediate discharge. Should you be the victim of sexual harassment by a co-worker, patient, or superior, you should contact the administrator of this practice immediately.
4. PERSONNEL RECORDS/HEALTH RECORDS
Personnel records are maintained on each employee. These are contained in the Personnel File and Employee Health Record. Information contained in the Personnel Record will include but not be limited to:a) resumeb) job application including name, address, telephone number, number of dependents, and the name and telephone number of an emergency contact person.c) annual calendar on which is recorded sick leave and vacation accruald) any personnel evaluations, performance reviews, reference letters
Health records are maintained on each employee as required by OSHA and will be kept in a separate folder from the personnel record. The health record is required by OSHA and will contain information as required by OSHA pertaining to training in bloodborne pathogens, Hepatitis B vaccinations, all job related accidents and any reported exposure incidents to blood or other potentially infectious material.
Please report any changes in the personal information maintained in either record.Your records are considered confidential and will be accessible only to you, your supervisor and the administrator of this practice. Information will not be released to anyone outside the organization without a court order or your written authorization. Records will be kept for the duration of employment plus thirty years.
5. STANDARDS OF CONDUCT/WORK PLACE RULES
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It is understood that at all times staff are expected to treat one another and all patients with respect and courtesy, and in accordance with the Practice Act of your particular profession. In appropriate behavior can include but not be limited to insubordination, incompetence, dishonesty including the falsification of records, removal of records or property without written consent, possession or use of firearms or chemicals while on duty All health and safety precautions must be observed and followed. All professional ethics and laws including HIPPA must be observed at all times in regard to patient confidentiality and confidential information.Certain rules of personal conduct are necessary to maintain the efficient and orderly procedures. The subjects discussed here include the most common ones, although there may be other situations where corrective action is needed. Your cooperation in observing all stated rules and regulations and using good common sense in your work should make any disciplinary action unnecessary.
Treatment of Others: It is understood that at all times staff are expected to treat one another and all students and school personnel with respect and courtesy, and in accordance with the New York State Practice Act, the Code of Ethics of the AOTA and APTA and the Guide for Professional Conduct of your particular profession. Copies of the Code of Ethics for Physical and Occupational Therapists are given to each therapist and a signed copy that the therapist accepts the code of ethics as the basis of their practice of their profession are made part of each personnel folder.
Health and Safety Precautions: Violation of safety rules, failing to report an on the job injury or accident, failing to report any incident involving a student, working while intoxicated or under the influence of any substance that impairs judgment or physical abilities are examples of unacceptable behavior.
Confidential Information - All professional ethics and laws including HIPPA must be observed at all times in regard to confidentiality and confidential information you may be privileged to during the course of your work.
Work Performance: Each employee has the responsibility of making sure that the patients in their care receive the best possible care in the most efficient manner. A student’s treatment and safety always comes first. Not performing your work, being rude, inattentiveness to the job, causing unnecessary waste and spending unreasonable amount of time on personal business while at work are examples of unacceptable performance and cause for disciplinary action.
Conduct – The following examples of improper conduct are given for your information. This listing of examples is not comprehensive or all inclusive. Should you engage in any of the following, you will be subject to disciplinary action including immediate discharge:A. InsubordinationB. IncompetenceC. Dishonesty, including falsification, removal of property without authorization, misrepresentation, alteration or omission of relevant information. D. Willful destruction and/or unauthorized removal of propertyE. Fighting or disorderly conduct while on duty.F. Possession or use of firearms, weapons or chemicals while on duty
Disciplinary Procedures
Violation of rules will result in disciplinary action such as verbal or written warning, suspension, or immediate discharge. Disciplinary action will be instituted at the discretion of management according to the severity of the violation. Please bear in mind that our strong
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preference is that we never have to undertake disciplinary action against anyone. Everyone’s cooperation is appreciated. Disciplinary action usually follows these step but we reserve the right not to be limited to this process. In addition, any of the steps below maybe superceded at any time under the advice of the Office of the Professions and or the NYS Board of Regents.
1. Verbal Warning – A verbal warning is given by your supervisor. The supervisor will document the conversation and provide you with a copy. A copy will also be placed in your personnel file.2. Written Warning – Written warnings are given by your supervisor when conduct or performance has not improved following a verbal warning. The infraction is documented with a copy given to you and one placed in your personnel file.3. Suspension – A letter of suspension is given by your supervisor for severe violations. A copy of the letter is placed in your personnel file and a copy is given to you.4. Discharge – This form of disciplinary action is used when other actions have failed to produce the desired behavior.5. Immediate Discharge – Immediate discharge may occur with prior warnings in cases of misconduct, dishonesty, disclosure of confidential information etc.
Problem Resolution
It is the objective that each employee receive fair and equitable treatment. In order to provide a smooth working relationship there are certain general steps which employees should follow in resolving problems. Every effort should be made to find an acceptable solution by informal means with an employee’s supervisor before continuing with the resolution process. If you feel there is a problem you should proceed by:
1. Discussing the problem verbally with your supervisor as soon as possible. Your supervisor should make every effort to reach a satisfactory conclusion to the dispute within five (5) working days or the time specified by your supervisor.
2. If no agreement is reached, you should present the problem in writing to your supervisor. The written statement is to be signed by you and should include the nature of the problem and the circumstances from which it arose, the remedy or correction requested to be made, the section or sections of the policy if any relied upon or claimed to have been violated.
Management will review the problem within three (3) working days, and an expedient attempt to resolve the dispute will be made. Management will submit the final results in writing to the parties involved in the problem.
Termination of Employment
Circumstance may arise in which termination is necessary. You may terminate employment at any time and for any reason; ________ retains a similar right and stresses the fact that employment is not set for a definite period of time.
Voluntary Termination – You may resign by notifying your supervisor or management of your desire. We ask that you advise us in writing at least two weeks (14 days) in advance. We realize that this may not be possible in all situations but we ask for your cooperation. A copy of the resignation letter will be placed in your personnel file.Any unreported absence of three (3) or more consecutive days will be considered a voluntary resignation.
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Involuntary Termination – In voluntary termination includes a discharge, permanent layoff, or any termination by _______. If you are terminated involuntarily, Management will:
a. Verbally inform you that you are terminated and give you the reasonb. Write down the actual incidents leading to your discharge and the reasons for the discharge. This documentation will be kept in your personnel file with a copy given to you.
6. COMPENSATION/HOURS OF WORK
The work week will begin on Monday and will be scheduled seven days in advance. Each employee will be notified of their scheduled work hours, which may change sporadically.
Paid holidays will include the following: New Year’s Day, Christmas Day, Labor Day, Memorial Day, Independence Day, Thanksgiving.
Pay periods will be biweekly. It is your responsibility to accurately fill in your time sheets. Records of your time must be kept on a daily basis, in your own hand writing. Time sheets must include your name, address and social security number, and need to be turned in on time to insure timely pay checks. From your paychecks, deductions will be taken for Federal and State Income taxes, social security taxes, and any other deductions required by law. Overtime will be paid for all timed work in excess of 40 hours.
8. BENEFIT PLANBenefits plans are subject to change from time to time, and all staff are required to pay for their benefits. The terms of the specific plans are control by the carrier including eligibility, benefits determination and other conditions. A summary description plan is available from the administrator.
SAMPLE PERSONNEL APPLICATION & INFORMATION INTAKE FORM
_______________________ is committed to providing and promoting equal employment opportunities for all applicants and employees. It is also the policy and practice of the company to hire, train, promote, compensate and administer all employment practices
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without regard to race, color, religion, sex, national, origin, age, marital status, medical condition, veteran status, sexual orientation or disability unrelated to the ability to perform the essential functions of the job. Furthermore, the company is committed to complying with the Americans with Disabilities Act. If you believe that you need a reasonable accommodation in order to complete an application for employment due to the fact that you have a disability, please notify the company within three (3) days of you application of you specific needs for a reasonable accommodation so that the company can assist you where appropriate. If an applicant requests an accommodation for purposes of completing the job application process, the company reserves the right to require the applicant to furnish documentation from an appropriate professional (ie. doctor, rehabilitation counselor, etc) confirming that the applicant has a disability or concerning their functional limitations for which a reasonable limitations accommodation is requestedIn order that your application may be properly evaluated, it is essential that all of the following questions be answered carefully and completely. If you need more space for your answers, Please attach a separate sheet. Feel free to add any additional information which will help us with placing you where you are best qualified. Please print in ink or use a typewriter.
DATE: ___________
Name: _____________________________ Business name _____________________ Discipline: __________________________ (if clinical staff) SS# or Tax ID # ________________________Phone No:(H) __________________ (W)__________________ (cell)_________________
In case of emergency please notify: __________________________________________________________________Best Time/Place to reach you: ____________________________________________Availability to work immediately: ____ Hours available: __________________________Days available: _________________________________________________________
Languages other than English: ____________________________________________
Areas of Expertise (if clinical staff)_______________________________________
Other Info: 1. Have you ever had your therapy license revoked or suspended: Yes__ No__ NA__If yes, please explain: Attach additional page if necessary. ____________________________________________________________________________________________________________________________________
2. Do you have the legal right to work and remain in the United States? __________________________________________________________________
3. Have you ever been convicted of a felony, misdemeanor, or any offense other than a minor traffic violation? Yes _________ No ________ . If yes, please explain ____________________________________________________________________________________________________________________________________
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4. Have you ever committed an offense involving dishonesty or breach of trust or fraud? Yes ___________ No ___________. If yes, explain __________________________________________________________________5. Is there any information relative to change of name necessary to enable _____ to check references of prior employees? ____________________________________________________________________________________________________________________________________
6. Have you had any malpractice claims, suits or settlements in the last five years? Yes___No___ If yes, please explain: ____________________________________________________________________________________________________________________________________ 7. To your knowledge are there any claims that have not been filed yet, but you have put on notice about intent to file? Yes ______ No ________ If yes please explain ____________________________________________________________________________________________________________________________________________________________________________________________________________
All information submitted in this application is warranted to be complete, correct and true. I authorize ______________________to consult with the _________State Board of Regents, the Office of the Inspector General, the National Practitioners Data Bank, specialty boards, malpractice insurance carriers and any other person or entity from whom/which information may be needed prior to gainful employment. I authorize all such entities to release such information to ______________________. I release ______________and its employees from any and all liability for their acts performed in good faith and without malice in obtaining and verifying such information and in evaluating this application.
________________________________________ ___________________Signature Date
PHYSICAL THERAPY CODE OF ETHICS
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This Code of Ethics of the American Physical Therapy Association sets forth principles for the ethical practice of physical therapy. All physical therapists are responsible for maintaining and promoting ethical practice. To this end, the physical therapist shall act in the best interest of the patient/client. This Code of Ethics shall be binding on all physical therapists.
PRINCIPLE 1A physical therapist shall respect the rights and dignity of all individuals and shall provide compassionate care.
PRINCIPLE 2A physical therapist shall act in trustworthy manner towards patients/clients, and in all other aspects of physical therapy practice.
PRINCIPLE 3A physical therapist shall comply with laws and regulations governing physical therapy and shall strive to effect changes that benefit patients/clients.
PRINCIPLE 4A physical therapist shall exercise sound professional judgment.
PRINCIPLE 5A physical therapist shall achieve and maintain professional competence.
PRINCIPLE 6A physical therapist shall maintain and promote high standards for physical therapy practice, education and research.
PRINCIPLE 7A physical therapist shall seek only such remuneration as is deserved and reasonable for physical therapy services.
PRINCIPLE 8A physical therapist shall provide and make available accurate and relevant information to patients/clients about their care and to the public about physical therapy services.
PRINCIPLE 9A physical therapist shall protect the public and the profession from unethical, incompetent, and illegal acts.
PRINCIPLE 10A physical therapist shall endeavor to address the health needs of society.
PRINCIPLE 11A physical therapist shall respect the rights, knowledge, and skills of colleagues and other healthcare professionals.
I accept this Code of Ethics as the basis for the practice of my profession.
_________________________________________ ______________Signature Date
OCCUPATIONAL THERAPY CODE OF ETHICS -
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Principle 1. Occupational therapy personnel shall demonstrate a concern for the well-being of the recipients of their services. (beneficence)
Principle 2. Occupational therapy personnel shall take reasonable precautions to avoid imposing or inflicting harm upon the recipient of services or to his or her property. (non malfeasance)
Principle 3. Occupational therapy personnel shall respect the recipient and/or their surrogate(s) as well as the recipient's rights. (autonomy, privacy, confidentiality)
Principle 4. Occupational therapy personnel shall achieve and continually maintain high standards of competence. (duties)
Principle 5. Occupational therapy personnel shall comply with laws and Association policies guiding the profession of occupational therapy. (justice)
Principle 6. Occupational therapy personnel shall provide accurate information about occupational therapy services. (veracity)
Principle 7. Occupational therapy personnel shall treat colleagues and other professionals with fairness, discretion, and integrity. (fidelity)
I accept this Code of Ethics as the basis for the practice of my profession.
Speech Language and Hearing Therapists ASHA Code of Ethics
Principles of Ethics 1 -Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally.
Principles of Ethics 2 – Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence.
Principles of Ethics 3 – Individuals shall honor their responsibility to the public by promoting public understanding of the professions, by supporting the development of services designed to fulfill the unmet needs of the public, and by providing accurate information in all communications involving any aspect of the professions.
Principles of Ethics 4 – Individuals shall honor their responsibilities to the profession and their relationships with colleagues, students and members of allied professions. Individuals shall uphold the dignity and autonomy of the professions, maintain harmonious interprofessional and intraprofessional relationships and accept the professions’ self imposed standards.
Sample Business Continuity Plan in Case of Disaster
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Business Name___________________________________________Address__________________________________________City, State__________________________________________Tel. No(s)
___________________________________________Designated Primary Crisis Manager__________________________________________Telephone No (s) Include cell__________________________________________E-mail Address
___________________________________________Back up Crisis Manager___________________________________________Telephone No (s) Include cell___________________________________________E-mail Address
EMERGENCY CONTACT INFO:Dial 911 in an emergency___________________________________________Tel No. Non emergency local Fire, Police___________________________________________General Liability Insurance POl # and Tel. No___________________________________________Malpractice Insurance POL # and Tel No.___________________________________________Business interruption Ins. Pol #, Tel #.__________________________________________Landlord Telephone No.___________________________________________Electric Company Acct # and Contact No.
___________________________________________Bank Account #, Bank Tel No.
If Primary location is inaccessible we will operate from address below:__________________________________________Address___________________________________________City, State___________________________________________Tel. No(s)
Emergency Planning Team: The following people will participate in emergency planning /crisis management (include anyone with CPR/EMS certification_________________________________________
___________________________________________
Coordination with Neighboring Businesses:___________________________________________Name/Tel #
CRITICAL OPERATIONS: The following is a prioritized list of critical operations, staff and procedures we need to recover from a disaster:_______________________________________________________________________________________________________________________________Operation, Staff in Charge, Action Plan
_________________________________________________________________________________________________________________________________Operation, Staff in Charge, Action Plan
_________________________________________________________________________________________________________________________________Operation, Staff in Charge, Action Plan
EVACUATION PLAN: We have reviewed these plans with landlord and neighboring businesses to avoid gridlock/confusion. We have located and posted building and site maps, our exits are clearly marked and we will practice evacuation procedures __x per year. If we must leave the work place quickly we will:____________________________________________________________________________________________________________________________________________________________________________
SHELTER IN PLACE: We have talked to all staff about what emergency supplies we have on hand in case we need to take shelter in place. We have a portable kit that includes first aid supplies, water, batteries, a flashlight and a copy of this plan. If we must take shelter quickly on site we will:____________________________________________________________________________________________________________________________________________________________________________
COMMUNICATIONS: We will communication our emergency plans with staff in the following ways:____________________________________________________________________________________________________________________________________________________________________________
CYBER SECURITY: To protect our computer hardware we will: ______________________________________________________________________________________To protect our computer software we will:______________________________________________________________________________________If our computers are destroyed or stolen, we will use back-up computers at the following location:_________________________________________________________________________________________________________________________________
RECORDS BACK-UP:
_____________________ is responsible for backing up all critical records including patient info, payroll and accounting.
Back-up records including a copy of this plan, site maps, insurance policies, banking info and
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computer back ups are stored onsite at the following place:____________________________________________________________________________________________________________________________
Another set of records are stored off-site at:_________________________________________________________________________________________________________________________________
Our plan for payroll continuity: ______________________________________________________________________________________We have the following fire-proof file cabinets:______________________________________________________________________________
We have a safety deposit box: ______________________________________________________________________________________EMERGENCY CONTACT INFO For EACH EMPLOYEE:___________________________________________Name/ Tel #_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ANNUAL REVIEWThis plan was created: Date: ___________________Date of Review:____________
FORM: INDEPENDENT CONTRACTOR AGREEMENT
THIS AGREEMENT made this _________________ day of ________________20____Between a ____________ duly organized and existing under the laws of the ____________ (hereinafter known as the __________ and
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______________________________________________________ a professional duly authorized under the laws of the State of ____________ and having their principal office at ______________________________________________________ (hereinafter known as the “Provider”)
WHEREAS,
A. __________ desires to contract for the provision of services, the nature character and extent of which is set forth in this agreement, and
B. The Provider is a licensed and qualified ________________________ professional therapist and desires to render such services for _________ clients,
NOW, THEREFORE, in consideration of the mutual promises herein contained, and other good valuable consideration, the parties hereto agree as follows:1. Services:
(a) The Provider shall be added to the roster of service providers maintained by __________ and shall be offered assignments to perform services for the _________clients as a service provider when such services are needed, and as _________ deems appropriate.
(b) The Provider may accept or refuse any assignments offered by the __________ and may accept as few or as many assignments offered (including none at all) as he/she may elect. The provider may, after accepting an assignment, upon providing four weeks notice, drop any assignment accepted.
(c) Nothing contained here shall prevent the Provider from contracting with any other business entity that provides the same or similar services as the _______ or competing directly with the __________ for the same clients. This agreement does not impose any obligation on the __________ to actually utilize the services of the Provider.
(d) The provider shall retain control and the right to exercise professional judgment over the manner, means, details, and methods by which services to the Agency’s clients are performed so long as they comply with promulgated regulations from the _________ State Department of Health of the administrating Municipality.
(e) The Provider shall maintain her/her professional license, if applicable in the state of _________, and his/her registration as a professional with the administrating Municipality and will provide proof of license, renewal and certification when requested.
(f) The provider agrees that if, at any point, a legal action or appeal is initiated by any party, and if their presence is required, they are required to appear.
(g) In the event that training or attendance at seminar sessions is required for the Provider to perform services hereunder, the ________ shall have no responsibility to provide such training or seminar sessions.
(h) The Provider agrees to provide services to all clients without regard to race, color, creed, national origin, disability or source of payment.
2. Compensation:(a) The Provider will be compensated in the amount and the manner set forth in the
Service and Fee Schedule attached to and made part of this Agreement. The fee is agreed by the Provider for a qualified billable unit/service as established by the administrating Municipality
(b) The Provider acknowledges that the ___________ has made no representations or guarantees as to any minimum amount of fees, treatment hours or assignments that will be offered to him/her during the term of this agreement.
(c) The _____________ will not compensate the Provider for any unit(s)/service(s) which are not authorized by the administrating Municipality. The Provider understands that any billable unit/service that is denied by the administrating Municipality, if paid for, will be recouped.
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(d) It is agreed that the Provider is an Independent Contractor rendering professional services to the ____________. The Provider, as an Independent Contractor, is not an employee of the _________ and is not entitled to any employee benefits such as sick pay, paid vacation, bonuses, pensions or other benefits.
(e) The _____________ shall be under no obligation to provide worker’s compensation, disability, health, surgical or other such benefits, or to provide unemployment benefits or the Provider.
(f) There shall be no deductions or contributions made by the ________ for withholding, FICA, Medicare or other payroll taxes. The Provider shall, at all times, be an Independent Contractor, and shall therefore be liable for their own debts, obligations, acts and omissions. The Provider shall be responsible for the payment of all federal, state and local income taxes, FICA contributions, and the like on income earned pursuant to this agreement.
(g) The Provider agrees to retain for a period of four (4) years after providing services herein, this contract and such books, documents, and records as are necessary to verify the nature and extent of the costs of the services provided under the terms of this agreement.
(h) Upon written request, the Provider agrees to promptly provide the Comptroller General of the United States and the Secretary of the Department of Health and Human Services of the United States and their duly authorized representatives, for the purpose of inspection, audit and reproduction, access during regular business hours to this agreement and such books, documents and records as are necessary to verify the nature and extent of the costs of the services provided under this agreement.
3. Insurance and Indemnification:
(a) During the term of this Agreement, the Provider will purchase and maintain professional liability insurance covering his/her acts occurring within the scope of the services rendered hereunder. Coverage will be no less than One Million Dollars ($1,000,000.00) for each occurrence and will be no less than Three Million Dollars ($3,000,000.00) in the aggregate. Such insurance will name the __________ and it’s clients as additional named insured. The said policy shall not be canceled unless the Provider provides written notice to the ___________ thirty (30) days in advance of cancellation. The Provider shall submit satisfactory evidence of the policy before providing services under this agreement. Additional satisfactory evidence of the policy must be submitted upon request.
(b) Notwithstanding the above, the Provider agrees to indemnify and hold harmless the _______, its directors, officers, employees, subcontractors, and agents from and against any and all claims, expenses (including reasonable attorneys’ fees), liabilities or losses which may result or arise out of any and all malfeasance or neglect caused by alleged to be caused by the Provider connected with the rendering or failure to render services to any client. This subparagraph 3(b) will survive the termination of this agreement.
4. Expenses:
The Provider shall be responsible for all expenses which he/she may incur hereunder, including but not limited to, expenses for professional licenses and registrations, continuing education classes, automobile and any other transportation expenses and the cost of all telephone and fax use, tolls, supplies, materials, equipment or other paraphernalia necessary for the Provider to perform services under this agreement.
5. Tools, Supplies, Materials and Equipment:
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All tools, supplies, materials and/or equipment required by the Provider to perform services under this agreement shall be provided by the Provider and not the ____________
6. Independent Contractor Relationship:
(a) None of the provisions of this Agreement are intended to create and none shall be deemed to create, any relationship between the Provider and the ___________ other than that of independent entities contracting with each other for the purpose of effectuating the provisions hereof. Neither of the parties hereto will be construed to be the agent, representative or employee of the other.
(b) The __________does not control, directly or indirectly, the services that the Provider provides under this Agreement. The Provider acknowledges and agrees that the services performed by him/her are performed under the rules and regulations as designed and established by the administrating Municipality and the __________ State Department of Health promulgated regulations.
(c) As an Independent Contractor, the Provider agrees that he/she has no right to nor will he/she seek unemployment insurance benefits, workers’ compensation or disability benefits from the municipality that governs the program where services are provided or any other state based on the services rendered pursuant to this agreement.
(c) It is the responsibility of the Provider to ensure that he/she maintains Independent Contractor status as defined by and to the satisfaction of the Internal Revenue Service or any other governmental agency.
1. Term and Termination:(a) The term of this Agreement shall be for a period of two (2) years. This
Agreement may be renewed by either party by giving written notice to the other within thirty (30) days prior to the expiration of the current term.
(b) This Agreement may be terminated by either party with or without cause upon thirty (30) days prior written notice.
2. Dispute Resolution:
Any dispute or controversy arising out of or under this Agreement shall be submitted to the arbitration in the Municipality that governs the program where services are provided pursuant to the rule of the American Arbitration Association and any award rendered shall be final and binding and may be entered as a judgment in the courts of the Municipality that governs the program where services are provided.
3. Applicable Law:
This agreement shall be governed by the Municipality that governs the program where services are provided.
4. Miscellaneous:
(a) Any notice required by this Agreement will be in writing and will be given to the parties at their respective addresses set forth above by hand or by certified mail, return receipt requested, and if mailed, it will be deemed to have been given on the second day following the day so mailed.
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(b) This Agreement embodies the entire Agreement and Understanding between the parties and supersedes all prior Agreements and Understandings relating to the same subject matter.
(c) This Agreement may be modified or waived only by an instrument in writing signed by the party against whom enforcement of the modification or waiver is sought.
IN WITNESS WHEREOF, this Agreement has been duly executed and signed by:INDEPENDENT CONTRACTOR:
SIGNED:________________________ ______________________________Provider’s Name – please print
Title:____________________________ ______________________________Lic # _______ Social Security Number
NPI # _____
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FORM: EMPLOYMENT AGREEMENT
THIS AGREEMENT is made this ________ day of _________, 200 between _____________ (the “Company”), a ______________________________, and ____________________________, the undersigned professional (the “Therapist”) residing at ________________________________
RECITALSA. The Company desires to employ the Therapist, and the Therapist is willing to be
employed by and serve the Company on the terms and conditions herein provided.B. To effectuate the foregoing, the parties wish to enter into an employment agreement on
the terms and conditions set forth below.
Accordingly, the parties hereto agree as follows:1. SERVICES OF THE COMPANY. The Company is primarily engaged in the business
of providing the services of __________________________________________________________________________________________________________________________________________________to ____________________________________________________________________________________________________________________________________________________
2. SERVICES OF THERAPISTS. The Therapist is hired by the Company to provide his or her professional services to Clients and Client Agencies. The Therapist agrees to:
(a) Maintain his or her professional license to practice in the State of ______ and professional registration with the State of ______________Department of Education and to provide proof of licensure, renewal and certification when requested.
(b) Perform his or her services in accordance with the currently approved methods, practices and Code of Ethics of his or her profession.
(c) Provide pertinent professional credentials, when requested by Clients and to complete and submit such documents or forms as may reasonably assist the Company when servicing Clients
(d) Refrain from communicating, revealing or divulging, or making accessible to anyone other than the Company, or persons, firms, corporations, or other entities designated by the Company for such purpose, any confidential information, including, but not limited to confidential patient information, which is not generally available to the public and which is received by him or her during his or her period of employment with the Company.
3. TERM. The term of this Agreement shall be for a period of one (1) year commencing with the date of execution of this Agreement. This Agreement will be automatically renewed yearly.
4(a). TERMINATION WITHOUT CAUSE. This Agreement may be terminated without cause by either party upon thirty (30) days written notice. Within ten (10) days of termination of the Therapist’s employment with the Company for any reason, the Therapist shall turn over to the Company all Company property, including, but not limited to all papers and records in the Therapist’s possession, regardless of the form or medium in which such papers or records are kept, pertaining to patients, Clients and/or Client Agencies.4(b). TERMINATION FOR CAUSE. The Company may terminate the Therapist’s employment hereunder without thirty (30) days notice: (i) upon the failure of the Therapist to perform or observe in any respect any of the material terms or provisions of this
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Agreement; or (ii) upon willful misconduct on the part of the Therapist that is damaging or detrimental to the Company.
5. INSURANCE AND INDEMNIFICATION. (a) Prior to the commencement of the term of this Agreement, the Therapist will
purchase and maintain professional liability insurance covering all acts which may occur within the scope of the services he or she will render hereunder. Insurance coverage must be no less than One Million ($1,000,000.00) Dollars per individual occurrence and must be no less than Three Million ($3,000,000.00) Dollars in the aggregate. Such insurance coverage must name the Company as an additional named insured. Within ten (10) days of signing this Agreement, the Therapist will arrange with his or her insurance carrier to provide the Company with: (i) a certificate of insurance which states that should such insurance be cancelled, terminated or reduced, the Company will receive ten (10) days prior written notice; and (ii) proof, by stamping or some otherwise demonstrable means, that the insurance premiums have been, and are continuing to be paid.
(b) Notwithstanding the foregoing, the Therapist agrees to indemnify and hold harmless the Company, its partners, officers, employees and agents from and against any and all claims, expenses (including reasonable attorneys’ fees), liabilities or losses which may result or arise out of any alleged malfeasance, neglect or misconduct, caused or alleged to have been caused by Therapist in connection with rendering or failing to render services to any patient, Client or Client Agency. This subparagraph (b) will survive the termination or expiration of this Agreement.
6. PAYMENT FOR SERVICES.
(a) Therapist will be compensated in the amount and manner as mutually agreed upon.
(b) Therapist acknowledges that the Company has made no representation or guarantee as to any minimum amount of hours or assignments that are to be offered or made to the Therapist during the term of this Agreement. The Company will not compensate the Therapist for any service that is not authorized in advance by the Client or Client Agency.
7. EXPENSES. Therapist will be responsible for all expenses, which he or she may incur, including, but not limited to professional licenses and registrations, continuing education classes, professional liability insurance, automobile and any other transportation expenses, and the cost of all equipment or other paraphernalia necessary to perform the Services hereunder.
8. AMENDMENT. This Agreement shall not be amended, altered or modified except by an instrument in writing duly executed by the parties hereto.
9 JURISDICTION. Any controversy or claim arising out of or relating to this Agreement or any alleged breach thereof, which cannot be resolved by informal means, shall be settled by litigation in the federal or state courts located in the State of New York.
10. INTERPRETATION. This Agreement shall be interpreted under the laws of the State of New York without regard to conflict of laws principles.
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IN WITNESS WHEREOF, the undersigned have executed this Agreement, as of the day and year first set forth above._________________________ By: _________________________________Therapist Name – Print Company
Name – Signature
TEMPORARY PERSONNEL SERVICES AGREEMENT
Whereas, on this _____ day of ____________, _________________ a provider of _____________________ personnel, and _________________________, a nursing home which is engaged in the business of providing health care services and in need of temporary rehabilitation therapy and medical services support personnel, in consideration of the mutual covenants contained herein have agreed to enter into this Agreement as follows:
1. The terms of this Agreement shall be for a period of one (1) year, commencing on ____________________ and continuing through and including ______________. This Agreement may be renewed at the end of the stated period by written Agreement of both parties. Either party hereto may, at any time during the term of this Agreement, upon sixty (60) days written notice to the other party, terminate the Agreement.
2. _____________shall furnish to _______________ qualified rehabilitation therapy personnel on an as-needed, as available basis and in accordance to the terms hereof. Qualified personnel are those individuals who meet state-established licensing board standards and guidelines for their respective professions. ______________ is responsible for supervision and instruction of the personnel regarding policies, procedures, operations, specifically including, without limitation, all necessary safety precautions, equipment handling, and services to be rendered.
3. _____________shall maintain and provide to ______________ upon written request, the following information for any personnel:
� Copy of SS card and current driver’s license� Proof of Citizenship – 1-9 and W -9 forms along with appropriate ID� Copy of Tax ID form, business certificate, P.C. or Incorporation Papers if applicable� Resume� Current Liability Insurance� Current Professional License/Registration� Yearly Physical Exam and/or Doctor’s Note (updated yearly) � Evidence of Mantoux (PPD) (updated yearly)� List of Inservices attended � Documentation of Rubella and Rubeola titer or immunization (date given and titer
level)� Two Professional Written References � Health Assessment and Freedom from Health Impairment Hepatitis B – signed decline
sheet or documented proof of vaccination
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� Employment Agreement � In-service Information on OSHA Bloodborne Pathogenes, Universal Precautions,
Hepatitis B Virus, Infection Control , and HIPAA training and compliance and Written Proof of Receiving Above
4. __________ will determine the scope and duration o the therapist’s activities on assignment and will professionally supervise the performance of these personnel during the hours of assignment.
5. _____________ will have the rights, at any time to shorten, terminate, extend or change the assignment of a therapist, generally or to a particular individual, for any reason whatsoever or no reason, subject to Notice of Cancellation terms as stated within.
6. __________ shall advise each therapist that the patient’s right to confidentiality must be respected and that no information concerning the patient shall be released to anyone without the prior written permission of the patient and _________. ____________ agrees to provide in-service education regarding the confidentiality requirements surrounding AIDs related information in accordance with _____ law as well as all privacy issues covered by HIPAA to any therapist who will be assigned .
7. Both _________ and ___________understand and agree that any personnel assigned to _________ pursuant to this Agreement shall be treated as an employee of ARS, and not as an employee, agent, partner, or venture participant of ____________. ______________ agrees not to hire directly any personnel assigned pursuant to this agreement, unless all parties involved are in agreement to this, and that a buy-out plan, not to be less than 35% of the first year’s salary of the personnel will be paid to _____.
8. Both parties agree to obtain and maintain during the term of this Agreement, or any extension or renewal thereof, professional liability insurance in the minimum amount of One Millions Dollars($1,000,000.00) per occurrence and Three Millions Dollars ($3,000,000.00)aggregate coverage for any personnel assigned pursuant to this Agreement.
9. ___________ agree to indemnify ___________against all liabilities and expenses arising from the negligent performance of services provided by personnel supplied by _________ as required by this Agreement.
10. __________ retains the right to determine, within reasonable discretion which personnel will be accepted for initial or repeated service. ___________ shall provide __________ with advance telephone notification of ____________ staffing needs. Further, __________ agrees to give ____________ at least twenty-four(24) hours cancellation notice of need of personnel coverage.
11.__________ agrees to remunerate _________ for personnel provided and charges incurred pursuant to this Agreement. _________ shall invoice monthly for personnel provided by _______to __________. Any outstanding balances not paid within sixty(60) days of the invoice date shall be subject to a late payment charge of 1.5% per month, or such lesser amount as necessary to ensure that such late charges do not exceed the maximum allowed by law.
12. The individual rates to be charged for personnel provided hereunder are attached hereto as Exhibit A.
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13. Notwithstanding any other provision in this Agreement, __________________ may immediately terminate this Agreement, at any time, without notice, if payment for services is not received by the 60th day after the invoice is mailed.
14. During the term of this Agreement and for one(1) year following termination of this Agreement for any reason, _________will not, directly or indirectly, employ or contract with any personnel referred or furnished by _________ hereunder, without the express written consent of ________. _______ and _______ agree that any breach of this provision will cause irreparable damage to _______ and that, in addition to the other remedies available at law, any injunction or other equitable remedy shall issue to enforce this provision.In addition, in the event of a breach by __________of this provision, _________ also agrees and warrants to pay _____ an amount equal to 75% of the personnel’s annual income at the date of termination of employment from _______. At any time during the term of this Agreement and for a one year period following termination, if _______ includes on its payroll any person formerly referred to ________ by ________, __________ is no longer responsible in any way for that person’s actions or omissions.
15. In the event of the commencement of suit to enforce any and all of the terms or conditions of this Agreement, the prevailing party in such litigation shall be entitled to recover such sums as the court may fix as attorney’s fees.
16. The terms of this Agreement shall be binding upon all successors in interest, agents and assigns of the respective parties.
17 The parties agree that in the event of a change of ownership by either party, __________shall pay to ________ all outstanding balances due and owing prior to the effective date of the transfer of interest.
18. This Agreement contains the complete agreement between the parties with respect to the subject matter thereof and ma not be modified except by written agreement signed by both parties. This Agreement supercedes all previous written or oral agreements between the parties with respect to the subject matter herein.
19. This agreement may not be assigned by either party without the written consent of the other party. Consent for one assignment does not waive the consent requirement for any subsequent assignment, but subject to the foregoing limitation, will insure to the benefit of and be binding upon the successors and assigns of the respective parties.
20. The validity and interpretation of any terms or provisions of this Agreement or of the rights and duties of the parties herein shall be governed by the laws of the State of New York.
21. The signatories herein below specifically warrant that such individual has the capacity and authority to represent, contract on behalf of, and bind the respective parties with regard to the obligations, rights, and duties contained herein.
22. Any notice required to be provided to any party to this Agreement shall be considered effective as of the date of deposit with the United States Postal Service by certified or registered mail, postage prepaid, return receipt requested and addressed to the parties at the following addresses:
TO :
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Executed on the day and year first written above.
By ______________________________________________________Its ___________________________________________
____ per hour for Speech Therapy, Occupational Therapy, Physical Therapy, Social Work, Nutrition
Reviewed _______ Revised _____
BOILER PLATE SCHOOL CONTRACT
This agreement is made between _______________________ as provider of rehabilitation therapy personnel, hereinafter referred as the “Agency” and ______________________________here in referred to as “District”. The terms of this agreement shall extend from ______________________________Now thereafter it is mutually agreed as follows:1. At the District’s request the Agency will place occupational, speech, physical or special educators to provide related services to district school aged children as mandated by the District personnel. All such therapists providing services hereunder shall be subject to the approval of the District. The District reserves the right to reject or request the replacement of any individual therapist. 2. Bills for services rendered will be submitted on a monthly basis and in accordance with the fee schedule listed as Exhibit A. Payment will be made within a thirty day period following submission of bill.3. Services will be provided to all district school aged children, as applicable, regardless of race, creed, color, national origin, gender or disability.4. The District retains final professional and administrative responsibility for any services rendered, however both parties agree and recognize that the individual therapists hereunder are not employees of the District. The agency further agrees that it shall defend, indemnify, and hold harmless the District, its Officers, directors, agents and employees for all loss, costs, damage and expense, including attorney’s fees, judgments, fines and amounts paid in settlements in connection with a threatened, pending or completed action, suit or proceeding, arising from any act, error omission, misstatement, misleading statement, neglect or breach of duties by the Agency or any of its employees taken or made in the performance of their obligations undertaken or reasonably assumed with respect to this agreement.
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5. The District shall retain responsibility for obtaining medical prescriptions from Parent/Guardian of students referred to the Agency for related services prior to referring students to the Agency. The District shall be responsible for advising the Agency of the specific mandated services to be provided, The District shall maintain prescriptions on file and forward copies upon request of the Agency or therapist. All services will comply with pertinent provisions of Federal, State and local statutes, rules and regulations.6. Should any part of this agreement for any reason be declared invalid, such declaration shall not affect the validity of any remaining parts of this agreement which shall remain in full force for the duration of the contract.7. The District shall not enter into a separate agreement with any practitioner referred by or working through or with the Agency for the duration of the contract and a one year period thereafter without the express consent of the Agency,8. Either party may terminate the agreement without cause upon thirty days written notice to the other party. Any notice required to be provided to any party to this Agreement shall be considered effective as of the date of deposit with the United States Postal Service by certified or registered mail, postage prepaid, return receipt requested and addressed to the parties at the following addresses:
TO Agency:
TO District:
In WITNESS WHEREOF, this agreement has been duly executed and signed by:
____________________________________ ____________________________ District Agency Date: _____________ Date: _______________ TEMPORARY HOME HEALTH PERSONNEL SERVICES AGREEMENT
Whereas, on this day of 200__ ,_____________________________________ (_____) as provider of rehabilitation therapy personnel, and ______________________________________ as a home health care AGENCY which is engaged in the business of providing health care services to clients at their homes in AGENCY’s licensed service area, in the State of __________, and an organization in need of temporary rehabilitation therapy and medical services support personnel, in consideration of the mutual covenants contained herein have agreed to enter into this Agreement as follows:
1. The terms of this Agreement shall be for a period of one (1) year, commencing on ____________________,200__ and continuing through and including ____________ 200___. This Agreement may be renewed at the end of the stated period by written Agreement of both parties. Either party hereto may, at any time during the term of this Agreement, upon sixty (60) days written notice to the other party, terminate the Agreement.
2. _________ shall furnish to AGENCY qualified rehabilitation therapy personnel on an as-needed, as available basis and in accordance to the terms hereof. Qualified personnel are those individuals who meet state-established licensing board standards and guidelines for their respective professions. AGENCY is responsible for supervision and instruction of the personnel regarding policies, procedures, AGENCY operations, specifically including, without limitation, all necessary AGENCY safety precautions, equipment handling, and services to be rendered.
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3. ____________shall maintain and provide to AGENCY upon written request, the following information for any personnel:
� Copy of SS card and current driver’s license� Proof of Citizenship – 1-9 and W -9 forms along with appropriate ID� Copy of Tax ID form, business certificate, P.C. or Incorporation Papers if applicable� Resume� Current Liability Insurance� Current Professional License/Registration� Yearly Physical Exam and/or Doctor’s Note (updated yearly) � Evidence of Mantoux (PPD) (updated yearly)� List of Inservices attended � Documentation of Rubella and Rubeola titer or immunization (date given and titer
level)� Two Professional Written References � Health Assessment and Freedom from Health Impairment Hepatitis B – signed decline
sheet or documented proof of vaccination � Employment Agreement � In-service Information on OSHA Bloodborne Pathogenes, Universal Precautions,
Hepatitis B Virus, Infection Control , and HIPAA training and compliance and Written Proof of Receiving Above
4. AGENCY shall provide ______ with a plan of care that includes the services to be performed. The patient shall be accepted for home health care only by the AGENCY which will be responsible for the development and revision of the plan of care bin accordance with acceptable federal, state and city policies and regulations. ______ will not alter the plan. _______ agrees that when indicated by the needs of the patients as determined by the AGENCY, the initial visit will be made within 48 hours of receipt and acceptance of the referral.
5. It will be the sole responsibility of the AGENCY to assess the needs for home health services and the resources of the patient and the patient’s family.
6. AGENCY will determine the scope and duration o the therapist’s activities on assignment. AGENCY will professionally supervise the performance of these personnel during the hours of assignment to AGENCY patients.
7. AGENCY will have the rights, at any time to shorten, terminate, extend or change the assignment of a therapist, generally or to a particular individual, for any reason whatsoever or no reason, subject to Notice of Cancellation terms as stated within.
8. Therapists shall furnish the AGENCY with signed and dated initial assessments and subsequent clinical progress notes for each home visit by each discipline, on forms provided by AGENCY. Notes should include a description of signs and symptoms, treatment or services rendered, patient’s reaction, any change in the patient’s conditions, patient/family instruction given and patient’s progress toward meeting goals of treatment plan. In addition, any unusual situation or circumstance which impacts on the safe care of the patients shall be transmitted verbally to the appropriate AGENCY nurse coordinator by the therapist as soon as possible. IN addition to visit by visit reporting, therapists will provide sixty (60) day summaries and discharge summaries.
9. _________ shall advise each therapist that the patient’s right to confidentiality must be respected and that no information concerning the patient shall be released to anyone
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without the prior written permission of the patient and AGENCY. ________ agrees to provide in-service education regarding the confidentiality requirements surrounding AIDs related information in accordance with NY law as well as all privacy issues covered by HIPAA to any therapist who will be assigned to AGENCY patients.
10. Both ____ and AGENCY understand and agree that any personnel assigned to AGENCY pursuant to this Agreement shall be treated as an employee of _____, and not as an employee, agent, partner, or venture participant of AGENCY.
11. Both parties agree to obtain and maintain during the term of this Agreement, or any extension or renewal thereof, professional liability insurance in the minimum amount of One Millions Dollars($1,000,000.00) per occurrence and Three Millions Dollars ($3,000,000.00)aggregate coverage for any personnel assigned pursuant to this Agreement. Both parties agree that the other party will be named as a secondary insured under the terms of the policy.
12. AGENCY agree to indemnify _____ against all liabilities and expenses arising from the negligent performance of services provided by personnel supplied _____ as required by this Agreement.
13. AGENCY retains the right to determine, within reasonable discretion which personnel will be accepted for initial or repeated service. AGENCY shall provide ________ with advance telephone notification of AGENCY’s staffing needs. Further, AGENCY agrees to give _________ at least twenty-four(24) hours cancellation notice of need of personnel coverage.
14. AGENCY agrees to remunerate _________ for personnel provided and charges incurred pursuant to this Agreement. _________ shall invoice monthly for personnel provided by _________ to AGENCY. Any outstanding balances not paid within sixty(60) days of the invoice date shall be subject to a late payment charge of 1.5% per month, or such lesser amount as necessary to ensure that such late charges do not exceed the maximum allowed by law.
15. The individual rates to be charged for personnel provided hereunder are attached hereto as Exhibit A.
16. Notwithstanding any other provision in this Agreement, __________ may immediately terminate this Agreement, at any time, without notice, if payment for services is not received by the 60th day after the invoice is mailed.
17. During the term of this Agreement and for one(1) year following termination of this Agreement for any reason, AGENCY will not, directly or indirectly, employ or contract with any personnel referred or furnished by ______thereunder, without the express written consent of ___________. AGENCY and __________ agree that AGENCY’s breach of this provision will cause irreparable damage to ___________ and that, in addition to the other remedies available at law, any injunction or other equitable remedy shall issue to enforce this provision.In addition, in the event of a breach by AGENCY of this provision, AGENCY also agrees and warrants to pay _________ an amount equal to 75% of the personnel’s annual income at the date of termination of employment from _________. At any time during the term of this Agreement and for a one year period following termination, if AGENCY includes on its payroll any person formerly referred to AGENCY by ________, ________ is no longer responsible in any way for that person’s actions or omissions.
18. In the event of the commencement of suit to enforce any and all of the terms or conditions of this Agreement, the prevailing party in such litigation shall be entitled to recover such sums as the court may fix as attorney’s fees.
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19. The terms of this Agreement shall be binding upon all successors in interest, agents and assigns of the respective parties.
20. The parties agree that in the event of a change of ownership by either party, AGENCY shall pay to _____________ all outstanding balances due and owing prior to the effective date of the transfer of interest.
21. This Agreement contains the complete agreement between the parties with respect to the subject matter thereof and ma not be modified except by written agreement signed by both parties. This Agreement supercedes all previous written or oral agreements between the parties with respect to the subject matter herein.
22. This agreement may not be assigned by either party without the written consent of the other party. Consent for one assignment does not waive the consent requirement for any subsequent assignment, but subject to the foregoing limitation, will insure to the benefit of and be binding upon the successors and assigns of the respective parties.
23. The validity and interpretation of any terms or provisions of this Agreement or of the rights and duties of the parties herein shall be governed by the laws of the State of New York.
24. The signatories herein below specifically warrant that such individual has the capacity and authority to represent, contract on behalf of, and bind the respective parties with regard to the obligations, rights, and duties contained herein.
25. Notwithstanding any other provisions in this contract, the licensed home care services AGENCY remains responsible for: a) ensuring any service provided pursuant to this contract complies with all pertinent provisions of federal, state and local statutes, rules and regulations, b) ensuring the quality of all services provided by the AGENCY, and c) ensuring adherence by AGENCY staff to the AGENCY plan of care established for patients.
26. Any notice required to be provided to any party to this Agreement shall be considered effective as of the date of deposit with the United States Postal Service by certified or registered mail, postage prepaid, return receipt requested and addressed to the parties at the following addresses:
TO ________________ PUT YOUR ADDRESS
TO AGENCY:
Executed on the day and year first written above.
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AGENCY:
By ______________________________________________________Its ___________________________________________
_________ per visit for Speech Therapy, Occupational Therapy, Physical Therapy, Social Work, Nutrition
CONFIDENTIAL INFORMATION NON-DISCLOSURE AGREEMENT
Effective __________________________________________________ desires to disclose to ______________________________________________________(hereinafter “RECIPIENT”), certain confidential information which RECIPIENT acknowledges to be of a confidential character, such information being relating to the finances, bookkeeping procedures, tax returns, client lists, client information, and any other information developed by the DISCLOSER in the operation of its business (hereinafter "Confidential Information").
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2. RECIPIENT accepts this Confidential Information for the sole purpose of evaluating the purchase of the assets of DISCLOSER’S business and practice, and hereby agrees not to make use of the disclosed Confidential Information, except for such purpose as evaluation, or to disclose the same to any third party or parties without the written prior consent of DISCLOSER. All such disclosures shall be in writing. All oral disclosures to RECIPIENT which are then summarized in writing within ten (10) days are also covered by this Agreement. RECIPIENT shall protect said Confidential Information with the same degree of care as it applies to protect its own.
3. Within ten (10) days or within any extension period granted by DISCLOSER from the date of this Agreement, RECIPIENT will advise DISCLOSER in writing as to its interest in negotiating an agreement to purchase DISCLOSER’S business. Should DISCLOSER independently agree to so negotiate with RECIPIENT, the parties will commence good faith negotiations upon DISCLOSER’S written notification to RECIPIENT.
4. If the period for evaluation has expired, or the RECIPIENT has notified DISCLOSER in writing that it is no longer interested in continuing with the evaluation, or if negotiations between the parties have commenced but DISCLOSER has notified RECIPIENT in writing that in DISCLOSER sole discretion a satisfactory agreement cannot be reached, then RECIPIENT will promptly return to DISCLOSER within ten (10) days all Confidential Information and copies thereof, including written documentation, and will keep only one copy thereof for the sole purpose of documenting this Confidential Information to RECIPIENT, and which will be maintained in confidence by RECIPIENT for the life of the Agreement as specified in Paragraph 9 below.
5. It is recognized that RECIPIENT may be required to disclose such Confidential Information to employees, for purposes of evaluation. RECIPIENT will exercise reasonable care in the selection of such employees, and will fully advise all such persons of the confidentiality of this Confidential Information and shall secure the agreement of all such persons to comply with the terms and conditions of this Agreement. The number of such employees will be limited to those who need to know for said evaluation purposes.
6. Notwithstanding the above, RECIPIENT shall have no obligation hereunder to refrain from disclosing specific information if and when a trademark and/or copyright is issued covering such Confidential Information. Further, RECIPIENT shall have no obligation hereunder to refrain from disclosing or using the following information:
(a) Information which is generally available to the public at the time of this disclosure;
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(b) Information which becomes part of the public domain or publicly known or available by publication or otherwise, not due to any unauthorized act or omission on the part of RECIPIENT;
(c) Information which thereafter is disclosed to the undersigned by third parties as a matter of right; and
(d) Information which has been independently developed by RECIPIENT.
7. In any event, it is understood that DISCLOSER does not release RECIPIENT from any liabilities based upon any trademark, copyright or other rights it now possesses or may acquire concerning such Confidential Information. No license or other right under any U.S. or foreign trademark, copyright, or other right is granted or implied by this Agreement.
8. The interpretation and validity of this Agreement and the rights of the parties shall be governed by the laws of the State of _______________.
9. The period of this Agreement is until three (3) years from either the termination of evaluation or negotiations by RECIPIENT or DISCLOSER whichever occurs last, as specified in Paragraph 3 above. All obligations of the RECIPIENT with respect to the use and disclosure of Confidential Information hereunder shall terminate at the end of such three (3)-year period.
10. RECIPIENT represents and warrants to DISCLOSER that i) it has the requisite corporate authority to enter into and perform this Agreement, and ii) this Agreement constitutes its legally binding obligation, enforceable according to its terms.
11. DISCLOSER represents and warrants to RECIPIENT that its execution and performance under this agreement, including his disclosure of Confidential Information to the RECIPIENT, will not result in a breach of any obligation to any third party or infringe or otherwise violate any third party’s rights.
12. RECIPIENT acknowledges that RECIPIENT’S breach of this Agreement may cause irreparable harm to DISCLOSER for which DISCLOSER is entitled to seek injunctive relief or other equitable relief as well as monetary damages.
13. Neither party shall assign or transfer this Agreement to any other person or entity, whether by operation of law or otherwise, without the prior written consent of the other party. Any such attempted assignment will be void and will have no effect.
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14. If and provision of this Agreement is found to by a proper authority to be unenforceable or invalid as a whole and in such event, such unenforceability or invalidity shall not render the Agreement unenforceable or invalid as a whole and in such event, such provision shall be changed or interpreted so as to best accomplish the objectives or such unenforceable or invalid provision within the applicable limits of law.
15. The above constitutes the full and complete Agreement in this matter by and between the parties hereto.
IN WITNESS WHEREOF, RECIPIENT has executed this Agreement consisting of four (4) pages in duplicate originals by its duly authorized officer or representative.
Print Name _______________________ Print Name _______________________
Title _______________________ Title _______________________
Date _______________________ Date _____________Please note that the contracts section does not replace consultation with a lawyer and are for informational purposes only. Individual clauses/ sections should be modified to meet the needs of your practice and state.
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