GENERAL HEALTH INFORMATION & HISTORY:
CONSENT TO TREAT & PROTECTED HEALTH INFORMATION POLICY:
The patient and/or guardian consent to the use of disclosure of protected health information by Axis Physical Therapy, Inc. for the purpose of providing treatment, obtaining payment and conducting health care operations. The patient and/or guardian understands that all treatment received from a Physical Therapist, Physical Therapist Assistant may be conditioned upon consent as evidence by signature on this document.
This patient and/or guardian have the right to request a restriction or revoke consent as to how any and all Protected Health Information (PHI) is used or disclosed, in writing, at any time. PHI refers to individually identifiable health information that is transmitted or maintained in any media. The patient and/or guardian have the right to review the Notice of Privacy Practices has been provided to the patient and/or guardian. The notice provides the types of uses and disclosures of PHI that might occur in treatment, the rights of the patient and the duties of Axis Physical Therapy, Inc. with respect to PHI.
Axis Physical Therapy, Inc. reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. The patient and/or guardian may obtain a revised copy of any such changes at the time of any following appointment, view the document online or request a copy by mail.
Insurance Payments:
By signing below the patient and/or guardian hereby authorize that insurance payments be paid directly to Axis Physical Therapy, Inc. The patient and/or guardian authorize the release of any information required to process insurance claims. Should any payment for services provided to the patient be made out in the patient’s name, the patient and/or guardian gives this office limited power of attorney to endorse any such check for deposit. The patient and/or guardian understands that they are financially responsible for any remaining balance.
During any treatment at Axis Physical Therapy, Inc. any balance accrued due to the deductible and/or coinsurance is payable within the month upon receipt of statement. If the financially responsible party is unable to pay within the month and fails to establish a payment plan, treatment may be suspended. Axis Physical Therapy, Inc. Takes all forms of payment and payments may be made in person, over the phone or by mail. When the patient’s treatment is concluded, suspended or terminated, all fees for professional services become immediately due within ninety days. If after ninety days there is no formal payment plan, the account balance is turned over for collection action and the patient/guardian will be responsible for all fees related to efforts in collecting an unpaid account balance. The patient and/or guardian acknowledges that co-payments, not billable to secondary insurance, are due at time of service.
Cancellation Policy:
24 Hour advanced notice is required to cancel any appointments the patient is unable to attend. Any no-show appointment or appointment cancelled with less than 24 hour notice will be subject to a $150.00 fee. This fee is not billable to insurance and will be applied to the patient’s account balance. If the patient misses three scheduled appointments without appropriate notification, Axis Physical Therapy, Inc. reserves the right to terminate all future care.
Cash Rate Patients:
Cash rate payments are due at the time of service. If the financially responsible party is unable to make cash rate payments at the time of treatment, it is the party’s responsibility to cancel any appointments with at least 24 hours' notice. By signing below, the patient and/or guardian acknowledges and agrees to the terms as written above.
