WELCOME Welcome to Neurosport Rehabilitation Associates. It is our goal to provide you with professional care and we will make every effort to see that you have an excellent experience with us. If you have any questions or concerns regarding your physical therapy, please feel free to discuss them with your therapists. INSURANCE As a patient receiving medical care, you should be aware of insurance coverage and limitations. We recommend you check with your insurance to understand your coverage. You are responsible for the charges incurred during your rehabilitation and as a courtesy; we will bill your insurance. After all charges have been billed to your insurance, a statement will be sent to you if there is a balance remaining. If you need a statement before that time, please contact our office. APPOINTMENTS In order to achieve your goals for recovery, regular attendance is necessary. Please check in at the front desk at which time your copay will be collected. As a courtesy, we ask that you contact us if you are going to be late or need to cancel. Please let us know at that time if you need to reschedule, if you will continue treatment at your next appointment or if you feel you no longer require physical therapy services. If you cancel your appointment with less than 24 hour notice or fail to show up for an appointment more than once, your future appointments may be removed from the schedule. A $25.00 missed appointment fee may be charged. I understand and agree to the above policy. X_____________________________________________ X_______________________________ Patient Signature Date If you would like us to bill your insurance, please read and sign the statement below. I authorize payment of medical benefits to Neurosport Rehabilitation Associates for physical therapy treatment. This includes major medical benefits to which I am entitled including Medicare and other government sponsored programs, private insurance, and any other health plans. I authorize the release of any medical or other information necessary to process my claims. This assignment will remain in effect until revoked by me in writing. X_____________________________________________ X_______________________________ Patient Signature Date
Transcript
WELCOME
Welcome to Neurosport Rehabilitation Associates. It is our goal to provide you with professional care and we will make every effort to see that you have an excellent experience with us. If you have any questions or concerns regarding your physical therapy, please feel free to discuss them with your therapists.
INSURANCE
As a patient receiving medical care, you should be aware of insurance coverage and limitations. We recommend you check with your insurance to understand your coverage. You are responsible for the charges incurred during your rehabilitation and as a courtesy; we will bill your insurance.
After all charges have been billed to your insurance, a statement will be sent to you if there is a balance remaining. If you need a statement before that time, please contact our office.
APPOINTMENTS
In order to achieve your goals for recovery, regular attendance is necessary. Please check in at the front desk at which time your copay will be collected. As a courtesy, we ask that you contact us if you are going to be late or need to cancel. Please let us know at that time if you need to reschedule, if you will continue treatment at your next appointment or if you feel you no longer require physical therapy services. If you cancel your appointment with less than 24 hour notice or fail to show up for an appointment more than once, your future appointments may be removed from the schedule. A $25.00 missed appointment fee may be charged.
I understand and agree to the above policy.
X_____________________________________________ X_______________________________ Patient Signature Date
If you would like us to bill your insurance, please read and sign the statement below.
I authorize payment of medical benefits to Neurosport Rehabilitation Associates for physical therapy treatment. This includes major medical benefits to which I am entitled including Medicare and other government sponsored programs, private insurance, and any other health plans. I authorize the release of any medical or other information necessary to process my claims. This assignment will remain in effect until revoked by me in writing.
X_____________________________________________ X_______________________________ Patient Signature Date
Informed Consent
Thank you for choosing Neurosport Rehabilitation Associates for your physical therapy. We appreciate you and your physicians' confidence in our service.
It is our philosophy that treatment be based on a thorough biochemical and neurophysiological evaluation. The results of the evaluation allow us to implement corrective treatment for your condition. This assessment may include reflex testing, sensory testing, muscle testing, and joint mobility/stability testing.
We will explain each step of the evaluation process. Should you become uncomfortable or the procedure becomes painful, please let your therapist know. We will be happy to explain the test function or modify the technique.
Once again, thank you for choosing Neurosport.
Respectfully,
The Staff of Neurosport Rehabilitation Associates
I have read and understand this information.
X____________________________ X_______________________ Patient Signature Date
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
We are required by law to maintain the privacy of your protected health information and to provide you with this Notice of Privacy Practices. We are also required to abide by the privacy policies and practices that are outlined in this notice.
Uses and Disclosures of Your Health Information
Treatment: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. The results of your evaluation will be available in your medical records to all health professionals who may provide treatment or who may be consulted by staff members.
Payment: Your health information may be used to seek payment from your insurance. Your insurance may request and receive information on dates of service, services provided, and the medical condition being treated.
Health Care Operations: Your health information may be used as necessary to support the day-to-day activities and management of the company. Information regarding the services you received may be used to support budgeting and financial reporting, and activities to improve quality.
Law Enforcement: Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting.
Public Health Reporting: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.
Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you must submit a written revocation of authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.
Additional Uses of Information
Appointment Reminders: Your health information will be used by our staff to send you appointment reminders.
Information About Treatment: Your health information may be used to send you information on the treatment and management of your medical condition or new technology that you may find to be of interest. We may also send you information describing other health-related goods and services that we believe may interest you.
Your Health Information Rights
You have certain rights under the federal privacy standards. These include: ► The right to request restrictions on the use and disclosure of your health information.► The right to receive confidential communications concerning your medical conditions
and treatment.► The right to inspect and copy your health information.► The right to amend and/or submit corrections to your health information.► The right to receive an accounting of how and to whom your health information has
been disclosed.► The right to receive a printed copy of this notice.
Our Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. The revised policies and practices will be applied to all protected health information that we maintain and will be available at our facility for you upon request.
Requests To Inspect Protected Health Information
As permitted by federal regulations, it is required that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records from the front desk.
Complaints
If you would like to submit a comment or complaint about our privacy practices, or if you believe your privacy rights have been violated, you can contact the company by sending a letter outlining your concerns to:
Terry Toth Neurosport Rehabilitation Associates
2296 Country Drive Fremont, Ca 94536
You may also file a written complaint with the Office of Civil Rights.
My signature on this form acknowledges that I have received and have access to a copy of Neurosport Rehabilitation Associates' notice of Privacy Practices. I understand that this document provides an explanation of the ways in which my health information may be used or disclosed and of my rights with respect to my health information.
I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
X_______________________________ X_______________________ Patient Signature Date
X_______________________________ X_______________________ Signature of Patient Representative Date (if patient is unable to sign)
To be completed by admitting clinician if above form is NOT signed
1. Was the patient provided with a copy of the agency's Notice of Privacy Practices? YES / NO
2. Briefly describe efforts made to obtain the patients acknowledgment of receipt of the noticeand explain why the patient was not able or willing to sign this form: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
X________________________ X____________________ Signature of Admitting Clinician Date
Insurance
Welcome to Neurosport Rehabilitation Associates. It is our goal to provide you with personalized and professional care during your period of rehabilitation. If you have any questions or concerns regarding your physical therapy, please feel free to discuss them with your therapist.
As a patient receiving medical care, you should be aware of your insurance coverage and limitations. You are responsible for the charges incurred during your rehabilitation. As a courtesy, we will bill your insurance. In order to do that you must provide the necessary insurance information at the time of your first visit. If this information is not received, you will be expected to pay in full for your visit or reschedule your appointment.
We will call your insurance to verify your copay and if any authorization is needed, however we are not able to quote your benefits to you. It is your responsibility to check with your insurance regarding your physical therapy benefits. A receipt will be given when any payment is made at our office. If you do not receive one please request one, since this will be your proof of payment.
If your insurance carrier does not remit payment within 90 days, the balance will be due and payable by you. Accounts not paid within 30 days after the insurance has paid may be placed in collection unless prior arrangements have been made with the patient account manager.
After all charges have been billed to your insurance company a statement will be sent to you if there is a balance remaining. If for any reason you need a statement before that time please contact our office.
I understand and agree to the above policy.
X________________________________ X________________________ Patient Signature Date
If you would like us to bill your insurance, please read and sign the statement below.
I authorize payment of medical benefits to Neurosport Rehabilitation Associates for physical therapy treatment. This includes major medical benefits to which I am entitled including Medicare and other government sponsored programs, private insurance, and any other health plans. I authorize the release of any medical or other information necessary to process my claims. This assignment will remain in effect until revoked by me in writing.
X________________________________ X_________________________ Patient Signature Date
NAME: _________________________________________
DOB: ___________________________________________
DATE: __________________________________________
CHART#: _______________________________________
Age: ___________ Sex: Male Female Are You: Right-Handed Left-Handed
Who referred you to the Physical Therapist? _____________________________________________________________
Living Environment
Does your home have?
Stairs, no railing Stairs, railing Ramps Elevator Uneven terrain
