ABOUT YOU


EMERGENCY CONTACT


MEDICAL HISTORY


MEDICAL INFORMATION


We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient. Our policy requires payment in full for services rendered at the time of visit.

INSURANCE INFORMATION


PLEASE NOTE: THRIVEAGAIN IS NOT A MEDICARE PROVIDER

NOTICE OF PRIVACY PRACTICES


Officer Name: Jessica Probst

Office Website: www.thriveagainpt.com

Office Phone Number: (202) 803-2068

Office Address: 1020 19th St. NW, STE 775, Washington, DC, 20036

Please Read Carefully

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and enable us to meet our professional and legal obligations to operate this medical practice properly. We are required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices with respect to protected health information. This notice describes how we may use and disclose your medical information. It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact our Privacy Officer listed above.

WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOUR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS.

For example:

1 Treatment: We may use and disclose your health information to a physician or other health care provider providing treatment to you.

2 Payment: We may use and disclose your health information to obtain payment for services we provide to you.

3 Health Care Operations: We may use and disclose your health information in connection with our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, and licensing or credentialing activities.

4 Your Authorization: In addition to our use of your health information for treatment, payment or health care operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

5 To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care, but only if you agree that we may do so.

6 Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your locations, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your health care.

7 Business Associates: We may share your medical information with our “business associates”, such as a billing service that performs administrative services for us. We have a written contract with each of these business associates that contains terms requiring them to protect the confidentiality of your medical information.

8 Appointment Reminders: We may use and disclose medical information to contact you by mail or phone and remind you about appointments. If you are not home, we may leave this information with the person answering the phone or on your answering machine.

9 Greeting you: We may call out your name when we are ready to see you.

10 Marketing: We may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments or health related benefits and services that may be of interest to you or to provide you with small gifts. We may also encourage you to purchase a product or service when we see you. We will not use or disclose your medical information for marketing purposes without your written authorization.

11 Required by Law: As required by law, we will use and disclose your health information, but we will limit our use or disclosure to the relevant requirements of the law when the law requires us to report abuse, neglect or domestic violence or respond to judicial or administrative proceedings of the law enforcement officials, we will further comply with the requirements set forth below concerning those activities.

12 Public Health: We may be required by law to disclose your health information to public health authorities for purposes related to: preventing or controlling, disease, injury or disability, reporting child, elder or dependent adult or neglect, reporting domestic violence, and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.

13 Health Oversight Activities: We may be required by law to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings.

14 Judicial and Administrative Proceedings: We may be required by law to disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have-not objected, or if your objections have been resolved by a court or administrative order.

15 Law Enforcement: We may be required by law to disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes.

16 To Avert a Serious Threat to Health or Safety: We may be required by law

to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

17 Specialized Government Functions: We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.

18 Workers Compensation: We may disclose your health information as necessary to comply with workers compensation laws. For example, to the extent of your care is covered by workers compensation, we may make periodic reports to your employer about your condition. We are also required by law to report cases of occupational injury or occupational illness to the employer or workers compensation insurer.

19 Changes of Ownership: In the event that this medical practice is sold or merged with another organization, your health information/record may be transferred to the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.

20 Incidental Disclosures: In the course of making disclosures of your health information for the purposes of treatment, payment and health care operations, we may also, as a by-product of these disclosures, make incidental disclosures. We will take reasonable safeguards to minimize the incidental disclosures.

21 Disclosure to Other Covered Entities: We may disclose your health information to another covered entity or a health care provider for the payment activities of the entity receiving the information. We may disclose your health information to another covered entity for the health care operations of the entity receiving the information, if the other covered entity has or has had a relationship with you and the information pertains to that relationship and the disclosure is for one of the following purposes:

* Health care fraud and abuse detection/compliances

* Quality assessment and improvement

* Population based activities relating to improving health or reducing health care costs

* Protocol development

* Case management and care coordination, contacting patients and providers with treatment alternatives

* Reviewing competence, performance or qualifications of professional providers and health plans and training programs.

22 Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose your health information in response to a judicial or administrative order. We may also disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute. We will make reasonable efforts to tell you about the request or to obtain an order protecting the information requested.

23 National Security and Intelligence Activities: We may release your protected health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

OUR RESPONSIBILITIES: We will not use or disclose your health information except as described in this Notice of Privacy Practice. This medical practice will not use or disclose health information that identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time, except to the extent that we have already acted in reliance on the authorization.

YOUR HEALTH INFORMATION RIGHTS

1) Right to Request Special Privacy Protections: You have the right to request restrictions on certain uses and disclosures of your health information by submitting a written request specifying what information you want to limit and what limitations on our use or disclosure of that information you wish to have imposed. We reserve the right to accept or reject your request and will notify you of our decision.

2) Right to Request Confidential Communications: You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular e-mail account or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.

3) Right to Inspect and Copy: You have the right to inspect and copy your health information, with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to and whether you want to inspect it or get a copy of it. We will charge a reasonable fee as allowed by law. We may deny your request under limited circumstances.

4) Right to Amend or Supplement: You have the right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and if we deny your request we will provide you with information about our denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is.

5) Right to an Accounting of Disclosure: You have a right to receive an accounting of disclosures of your health information made by this medical practice, except that this medical practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in the previous paragraphs.

6) Right to Receive a Notice of Privacy Practices: You have a right to receive a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt by e-mail. If you would like to have a more detailed explanation of these rights, or if you would like to exercise one or more of these rights, contact our Privacy Officer listed at the top of this Notice of Privacy Practices.

CHANGES TO THIS NOTICE OF PRIVACY PRACTICES: We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with this Notice. After an amendment is made, the revised Notice of Privacy Practices will apply to all protected health information that we maintain regardless of when it was created or received. We will keep a copy of the current notice posted in our reception area and provide you with a copy upon request.

COMPLAINTS: Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer listed at the top of this Notice of Privacy Practices.

You may also submit a complaint to:

Department of Health and Human Services Office of Civil Rights

Hubert H. Humphrey Building

200 Independence Avenue, S.W.

Room 509F HHH Building

Washington, DC 20201

You will not be penalized or subjected to retaliation for filing a complaint.

EVALUATION & TREATMENT FOR PHYSICAL THERAPY CONSENT


POTENTIAL RISKS

I may experience an increase in my current level of pain or discomfort, an aggravation of my existing injury or condition, an aggravation of a previously existing condition, or an onset of new symptoms. Any discomfort is usually temporary and if it does not subside in 48 hours, I agree to contact my physical therapist.

POTENTIAL BENEFITS

I may experience an improvement in my symptoms and an increase in my ability to perform daily activities and athletics. I may experience increased strength, flexibility, endurance and awareness with my movements. I may experience decreased pain and discomfort. I may gain a greater knowledge about managing my condition and the resources available to me.

ALTERNATIVES

If I do not wish to participate in the therapy program, I will discuss my medical, surgical or pharmacological alternatives with my physical therapist and my physician or primary care provider.

NO WARRANTY

I understand that there are no guarantees have been or can be provided regarding a cure for or improvement in my condition. I understand that if I am uncomfortable with the assessment or treatment procedures at any time, I will inform my therapist and the procedure will be discontinued and alternatives will be discussed with me.

CONSENT FOR THERAPEUTIC USE OF DIGITAL IMAGES AND VIDEOS

I give ThriveAgain Physical Therapy & Wellness permission to take photographs and videos of me for purposes such as documenting baseline function, functional progress, movement re-education and education on home exercises. I understand that these photographs and videos will be part of my confidential medical file and will not be used for any purpose beyond my medical care without my expressed written consent.

I have read or had read to me the foregoing and any questions, which may have occurred to me, have been answered to my satisfaction. I have informed my therapist of any condition that would limit my ability to have an evaluation or to be treated. I hereby request and consent to the evaluation and treatment to be provided by the physical therapists of ThriveAgain Physical Therapy & Wellness.

PATIENT FINANCIAL TERMS


APPOINTMENT INFORMATION

• The initial physical therapy appointment will last approximately 80 minutes, and subsequent appointments will usually last 50-55 minutes. Psychotherapy appointments last approximately 50 minutes.

• Please arrive promptly for each scheduled appointment. If the therapist is running late, the patient will not lose any treatment time. When the client is late for the session, the client incurs the loss of time and payment for the full session is expected.

• In the event that you are unable to attend your appointment, we require at least 24 hours / one business day advance notice. When you schedule an appointment with our practice, that time is reserved for you. When you miss the appointment without calling to cancel within a reasonable amount of time, your practitioner does not have the opportunity to offer that time to someone else in need of services. Missed appointments can also interfere with your progress in treatment. It is our policy that patients are responsible for all appointments that they have scheduled. IF YOU FAIL TO GIVE US 24 HOURS/ ONE BUSINESS DAY ADVANCED NOTICE, YOU WILL BE CHARGED FOR THE COST OF THE VISIT. Fees for missed appointments and/or late cancellations are expected at or before the patient’s next scheduled appointment. Insurance does not cover these fees. Any exceptional circumstances will be submitted for review.

• Any patient who misses more than two appointments without sufficient notice of cancellation during his/her course of treatment is subject to review and may be required to pre-pay for scheduled sessions.

IMPORTANT BILLING INFORMATION

ThriveAgain Physical Therapy & Wellness is NOT a participating provider with insurance companies. All charges are your responsibility from the date the services are rendered. We will be happy to provide you with a detailed invoice for you to submit to your insurance company for reimbursement. As a courtesy to our patients, we have a professional medical biller who will be happy to submit claims on your behalf to your insurance company. Though we are happy to file claims, we cannot take responsibility for ensuring your insurance company correctly applies the claims, and we are unable to guarantee that your insurance will reimburse you. Insurance companies vary the coverage they provide for out-of-network services, so we encourage you to verify your insurance coverage before your initial visit. It is ultimately your responsibility to pay ThriveAgain Physical Therapy & Wellness for the services and to assure that your insurance properly processes your claims. Please note that your insurance company may require that therapy services be prescribed by a physician, dentist, or podiatrist in order to reimburse you for costs incurred. This prescription should be provided on your initial visit.

PAYMENT INFORMATION

We accept personal checks, credit card (Visa, Master Card, American Express, and Discover) and cash. A minimum of $50 will be charged for any checks returned for insufficient funds.

ACKNOWLEDGEMENT

I have read and understood all of the above information, and agree to abide by all of its terms. Further, I understand that I am personally responsible for all charges, including those not covered by my insurance.

PAYMENT INFORMATION