PEAK PHYSICAL THERAPY
NOTICE OF PRIVACY
PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Uses and Disclosures:
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. For example, results of laboratory tests and procedures will be
available in your medical record 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 health plan, from other sources of coverage such as an automobile insurer,
or from credit card companies that you may use to pay for services. For
example, information on the services you received may be used to support
budgeting and financial reporting, and activities to evaluate and promote
quality.
Health care operations. Your health
information may be used as necessary to support the day-to-day activities and
management of Peak Physical Therapy. For example, information on services you
received may be used to support budgeting and financial reporting and
activities to evaluate and promote quality.
Law enforcement. Upon court order, 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
require your
specific written authorization. If you change your mind after authorizing a use
of disclosure of your information you may submit a written revocation of the
authorization. However, your decision to revoke the authorization will not affect or undo any use of disclosure of information that
occurred before you notified us of your decision.
Individual rights. You have certain rights under the
federal privacy standards. These include:
·
The
right to request restrictions on the use and disclosure of your protected
health information.
·
The
right to receive confidential communications concerning your medical condition
and treatment.
·
The
right to inspect and copy your protected health information.
·
The
right to amend or submit corrections to your protected health information.
·
The
right to receive an accounting of how and to whom your protected health
information has been disclosed.
·
The
right to receive a printed a copy of this notice.
Peak Physical Therapy duties. 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.
Requests to Inspect Protected Health Information. As permitted by federal regulation,
we require that requests to inspect or copy protected health information be
submitted in writing. You may obtain a form to request access to your records
by contacting your Physical Therapist.
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, please send us a letter outlining your concerns to:
Peak
Physical Therapy
You will
not be penalized or otherwise retaliated against for filing a complaint.
PEAK PHYSICAL THERAPY
Patient Information
Patient Name: Last: ______________________ First:______________________ Date of Birth: _____________
Address:
______________________________________
Male □ Female □ Marital Status ____________
City: _____________State: __________
Zip: __________ Is injury the result of an accident? (Y/N) ________
E-mail: ________________________________________
Work Related? (Y/N) ______Auto (Y/N) ________
Home Phone: ______________________ (Responsible party)
Work Phone: _______________________ Name:
___________________________________
Cell Phone:
________________________ Address:
_________________________________
Patient Employer: City:
Name:
______________________________________ Emergency Contact:
Address:
_____________________________________
Name: ___________________________________
City:
Occupation:
__________________________________ Prescribing
Doctor: ___________________________
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Please read the
following and Initial in the corresponding box. initials |
Initial |
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Consent to Treatment: I consent to rehabilitation and
related I doing so, I understand that such
rehabilitation and related services may involve bodily contact, touching, and/or direct contact of a
sensitive nature. |
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Treatment of Minors: I, as parent/guardian of a minor
receiving treatment, understand and agree that I have been advised to remain
on the premises during any such treatment, and waive any claim I may have resulting from failure
to do so. |
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Liability: I know and agree that Peak
Physical Therapy is not responsible for loss or damage to personal valuables. |
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Waiver and Release: I release Peak Physical Therapy
from all liability, damage, cause of action, or loss of any kind arising
out of or resulting from my refusal to accept, receive or allow emergency and or medical
services, including but not limited to
ambulance service, emergency medical technician, physician or urgent
care services. |
|
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Authorization of
Payment: I assign
all benefits directly to Peak Physical Therapy and authorize release of any medical records necessary
to facilitate my treatment to process medical claims. I understand that in the event my
insurance company does not pay for the services I receive, I will be financially responsible for
payment. |
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Notice of Privacy: I acknowledge receipt of the Peak
Physical Therapy Notice of Privacy Practices. |
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I certify that all of the information provided is true and
correct.
Patient/Guardian Signature: _____________________________________________
Date: ________________
Staff
Signature: _____________________
Provider: RPL GKA GC
TC
Patient
Account: ______________________
peak physical therapy
appointment cancellation / no show
policy
To: our patients
From: PEAK PHYSICAL THERAPY
We have had a number of patients who do not show up for
their appointment or who cancel their appointment at the last minute. This
practice impacts other patients and their ability to receive care in a timely
manner. For this reason,
Any appointments not rescheduled or cancelled at least 24
hours in advance will result in a charge of $20 to your account.
We appreciate your cooperation and consideration in this
matter. If you have any questions, please don’t hesitate to ask or call.
Please sign indicating that you understand this policy:
________________________________ ______________
Signature Date