Ability Health Services & Rehabilitation, LP Patient ... · ABILITY HEALTH SERVICES & REHABILITATION, LP PATIENT GUIDELINES AND CANCELLATION POLICY 1. Please get to your appointments

Ability Health Services & Rehabilitation, LP Patient History Form

Revised: 01.01.17

Patient Name: ________________________________________________________ D.O.B.: _______________________ SSN#:_____________________________________________ E-mail Address: ___________________________ Cell/Phone # ____________________________________________________ Age: ________ Sex: Male Female Marital Status (please circle): Single Married Divorced Religion: ____________________________ Emergency Contact Name: _____________________________________________________Phone #:________________________________Relation:_____________________ Race: Asian/Pacific Islander______ Hispanic______ Black______ Caucasian_______ Eskimo/American Indian________ Other________ Ethnicity: Hispanic or Latino______________ Not Hispanic or Latino_____________ Primary Language ______________________ Insurance are we billing for services rendered? Commercial_____Workers Comp______ Motor Vehicle______ Medicare______ Other____________ Current Problem: _____________________Date of Injury: ___Date of Surgery: Pain level (0-10) Current: ________ Best: ________ Worst: ________ Height: _______________ Weight:_________________ MEDICAL HISTORY (Do you have/had any of the following medical conditions?)_____________________________________________ YES NO YES NO HEART PROBLEMS? ____ ____ PACEMAKER? ____ ____ HIGH BLOOD PRESSURE? ____ ____ DIABETES? ____ ____ TB/HIV/HEPATITIS? ____ ____ CANCER? ____ ____ SEIZURES? ____ ____ PREGNANT? ____ ____ URINARY LEAKAGE? ____ ____ OSTEOPOROSIS? ____ ____ SMOKER? ____ ____ ALCOHOL? ____ ____ If smoker, how often:_________________________________________ If you drink alcohol, how often:_______________________________________ List any ALLERGIES: _________________________________________________________________________________________________________________________________________ List all surgeries, injuries, medical problems, or previous therapy that you have had in the past 5 years? _________________________________________________________________________________________________________________________________________________________________ List any medical conditions that may affect your therapy: _______________________________________________________________________________________________ Has your current situation caused any significant difficulty within your family/social life? YES_____ NO_____ If yes, describe: _______________________________________________________________________________________________________________________________________________ Describe the limitations you have: ________________________________ Your goals for therapy: __________ Employment/Work: Full-time_____ Part-time_____ Homemaker_____ Student_____ Retired_____ Unemployed_____ Occupation: _________________________________Employer: ________________________________Employer Phone: ______________________________________________ Briefly describe your occupation: __________________________________________________________________________________________________________________________ Do you currently use an Assistive Device? YES_____ NO______ If yes: Cane_____ Walker_____ Rolling Walker_____ Motorized Wheelchair_____ Other: _____________________________________________ With whom do you live? Alone_____ Spouse/significant other_____ Child/children_____ relative(s)_____ Group Setting_____ Personal care attendant_____ Other (describe):___________________________________________________________________________________________________________ Do you have a Power of Attorney? YES_____ NO_____ Representative: ____________________________________Phone # _____________________________ (Patient Signature): _ Date:

Ability Health Services & Rehabilitation, LP.

MEDICATION LIST

Patient Name: _____________________________________ DOB: ___________ Date: _________________

Prescription

Medication

Reason for Med Dose Frequency/Mode Prescribed by/Phone #:

Over the Counter

Medication

Reason for Med Dose Frequency/Mode Prescribed by/Phone #:

Patient Signature: ______________________________ Date:_______________________________

Ability Health Services & Rehabilitation, LP PATIENT CONSENT AND ACKNOWLEDGEMENT FORM

Patient Name: ____________________________________ Acct #: ______________________

I HEREBY AUTHORIZE ABILITY REHABILITATION TO FURNISH PHYSICAL, OCCUPATIONAL, SPEECH THERAPY OR ANY OTHER THERAPY TREATMENTS AS INDICATED BY MY REFERRING PHYSICIAN. I AUTHORIZE ABILITY REHABILITATION TO RELEASE ANY MEDICAL OR OTHER INFORMATION THAT MAY BE NECESSARY TO PROCESS MEDICAL CLAIMS ON MY BEHALF TO RELATED PHYSICIANS AND INSURANCE CARRIERS, WITH ADDITIONAL WRITTEN AUTHORIZATION TO ATTORNEYS, SOCIAL WORKERS AND REHABILITATION COUNSELORS. I AUTHORIZE ABILITY REHABILITATION TO INITIATE A COMPLAINT TO THE INSURANCE COMMISSIONER FOR ANY REASON ON MY BEHALF. I UNDERSTAND THAT ABILITY HEALTH SERVICES INC WILL BILL MY INSURANCE CARRIER FOR SERVICES RENDERED.

IF MY INSURANCE COMPANY FAILS TO RENDER PAYMENT FOR SERVICES RENDERED, I UNDERSTAND THAT I AM PERSONALLY RESPONSIBLE TO PAY MY BALANCE IN FULL AND I PERSONALLY GUARANTEE PAYMENT FOR MEDICAL CARE AND SERVICES RENDERED.

I HEREBY REQUEST THAT MY INSURANCE CARRIER MAKE PAYMENT DIRECTLY TO ABILITY REHABILITATION FOR ALL SERVICES RENDERED. IF MY CURRENT POLICY PROHIBITS DIRECT PAYMENT TO ABILITY REHABILITATION, I HEREBY INSTRUCT AND DIRECT MY INSURANCE CARRIER TO MAKE THE CHECK OUT IN MY NAME, BUT SEND THE CHECK TO ABILITY REHABILITATION. IF MY INSURANCE CARRIER MAKES PAYMENT TO ME, I AGREE TO IMMEDIATELY PAY OVER THESE FUNDS TO ABILITY REHABILITATION. I ALSO AUTHORIZE ABILITY REHABILITATION TO DEPOSIT CHECKS RECEIVED ON MY ACCOUNT WHEN MADE OUT TO ME.

FINANCIAL RESPONSIBILITY/ASSIGNMENT OF BENEFITS

1. IT IS YOUR RESPONSIBILITY TO PROVIDE US WITH ACCURATE DEMOGRAPHIC AND INSURANCE COVERAGE INFORMATION. ABILITY REHABILITATION WILL BE UNABLE TO ACCEPT YOUR INSURANCE IF PROOF OF INSURANCE AND/OR IDENTITY CANNOT BE VERIFIED. 2. SOME INSURANCE COMPANIES REQUIRE A WRITTEN REFERRAL OR PRIOR AUTHORIZATION BEFORE OUR THERAPISTS CAN SEE A PATIENT. IF THIS INFORMATION IS NOT OBTAINED PRIOR TO THE APPOINTMENT ABILITY REHABILITATION MAY NEED TO RESCHEDULE YOUR APPOINTMENT. 3. FOR YOUR CONVENIENCE ABILITY REHABILITATION WILL SUBMIT A CLAIM TO YOUR INSURANCE COMPANY ON YOUR BEHALF. YOU AGREE TO ASSIGN AND AUTHORIZE US TO BILL, COLLECT AND/OR NEGOTIATE PAYMENT BY THE INSURANCE PLAN ON BEHALF OF YOUR INSURANCE BENEFITS IN PLACE AT TIME SERVICES ARE RENDERED. 4. PAYMENTS FOR “OUT OF POCKET” OBLIGATIONS (I.E. COPAYMENTS, DEDUCTIBLES, COINSURANCES, AND OUTSTANDING BALANCES) MUST BE PAID PRIOR TO BEING SEEN. ABILITY REHABILITATION ACCEPTS THE FOLLOWING TYPES OF PAYMENT: CASH, CHECK, MONEY ORDER, DEBIT/CREDIT CARD (VISA, MASTERCARD, AMERICAN AND DISCOVER CARDS). 5. YOUR INSURANCE PLAN MAY NOT COVER ALL SERVICES AND/OR SUPPLIES PROVIDED TO YOU DURING YOUR TREATMENT WITH ABILITY REHABILITATION. IN THE EVENT YOUR HEALTH PLAN DETERMINES A SERVICE TO BE “NON- COVERED”, YOU WILL BE RESPONSIBLE FOR TOTAL CHARGES AT TIME OF VISIT OR UPON RECEIPT OF A STATEMENT. 6. IF YOUR INSURANCE PLAN DENIES OR DELAYS PAYMENT TO ABILITY REHABILITATION WITHIN A REASONABLE PERIOD PER STATE OF FLORIDA PROMPT PAYMENT RULES, YOU WILL BE RESPONSIBLE FOR PAYMENT IN FULL. SHOULD IT BE NECESSARY TO REFER THE ACCOUNT TO A COLLECTION AGENCY FOR COLLECTION, YOU WILL PAY REASONABLE COLLECTION EXPENSES INCLUDING BUT NOT LIMITED TO ATTORNEY FEES AND COURT COSTS, THERE WILL BE A $35 FEE FOR INSUFFICIENT FUNDS.

X________________________________________________________________________ _______________________

PATIENT/GUARDIAN DATE ______________________________________________________________________________________________ RELATIONSHIP TO PATIENT

FRONT DESK INITIALS: __________________

WC

Ins: ______________

Auto/PIP only Auto/ PIP/ Health Ins Auto Exhausted LOP Ins: ____________________

Medicare Medicare /Supplement Medicare Replacement

Ins: _________________________

Straight litigation Self -Pay Government Ins: ________________

Commercial Insurance __HMO/EPO __ PPO __ Other Ins: _________________________

YOU PAY:

$0

Unless you are at Maximum Medical

Improvement.

YOU PAY: Deductible $_____________ Co-Pay $ _______________ Co-Insurance % __________

YOU PAY: Deductible $___________________ Co-Pay $ _____________________ Co-Insurance % ________________ Cap $_________/_______________ Out of Pocket $ ________________ Visits PCY: _________/__________

YOU PAY:

$ __________

_________% Visit PCY: _____/______

YOU PAY: Deductible $__________________ Co-Pay $ ____________________ Co-Insurance %_______________ Out of Pocket $ _______________ Visits PCY: ________/__________

Authorization Required

Attorney Info required (if applies)

PCP Ref Required: YES or NO Auth Required: YES or NO

Auth Required

YES or NO

PCP Ref Required: YES or NO Auth Required: YES or NO

We will collect $______________up front TOWARDS your Coinsurance OR Deductible each visit.

Courtesy to you, we will bill your secondary/supplement insurance for your ______________ % coinsurance.

*** You will be billed any remaining responsibility of your coinsurance or deductible if applies. Benefits quoted by your insurance is not a guarantee of payment. ***

Revised: 01.01.17

ABILITY HEALTH SERVICES & REHABILITATION, LP

PATIENT GUIDELINES AND CANCELLATION POLICY

1. Please get to your appointments on time in order to allow adequate time for their therapy. Patients

arriving late for a scheduled appointment may not get full hour of treatment.

2. Please come appropriately dressed in attire that will allow you comfortable movement of the area to be

treated so you are able to perform physical activity such as gym shoes, shorts and t-shirts/tank tops.

3. All patients are required to sign in upon arrival.

4. Food, gum, and drinks other than water are not permitted in the patient treatment areas.

5. Cell phones should be turned off or be on vibrate to avoid disturbing other patients or interrupt

treatment.

6. Patients are required to wait in the waiting room areas until they are called in by a clinician.

7. Only the patient is permitted to go in the treatment area. Other adults or children are not permitted in

the treatment area unless prior arrangements have been made. Children are never permitted to use any

clinical equipment unless they are being treated.

8. A release for treatment must be filled out by any parent that must leave their children under the age of

18 during their therapy session. Children must be picked up promptly following therapy.

9. If you or your child are unable to keep your appointment due to illness or any other reason, please call at

least 24 hours in advance to reschedule your appointment. A cancellation/ no-show fee of $30.00 may

be charged.

10. Attending your scheduled therapy sessions is one aspect of your treatment that you can control. In the

event of cancellation of less than 24 hours, or you miss your appointment the following policies will

apply:

- First offense- we will verbally request to follow our cancellation policy.

- Second offense- your physician, case manager, and/or insurance company will be notified if you miss

your appointment without reasonable cause.

- Third offense- inability to schedule with written notification of non-compliance to physician, case

manager, and/or insurance company.

Your signature certifies that you have read the Cancellation Policy and accept its terms

_________________________________________________________________________ _______________________

PATIENT/GUARDIAN DATE

_________________________________________________________________________ _______________________ RELATIONSHIP TO PATIENT DATE

ABILITY HEALTH SERVICES & REHABILITATION, LP

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

Ability Health Services, Inc My “protected health information” means health information, including my demographic

information, collected from me and created or received by my physician, rehab facility, another

health care provider, a health plan, and my employer or a health care clearinghouse. This

protected health information relates to my past, present, and/or future physical or mental health or

condition and identifies me, or there is a reasonable basis to believe the information may identify

me. I understand I have the right to request a restriction as to how my protected health

information is used or disclosed to carry out treatment, payment, or healthcare operations of the

practice. Ability Health Services is not required to agree to the restrictions that I may request;

however, if Ability Health Services agrees to a restriction that I request then the restriction is

binding. I have the right to revoke this consent, in writing, at any time, except to the extent that

Ability Health Services has taken action in reliance on this consent.

I understand I have the right to review Ability Health Services Notice of Privacy Practices, which

has been made available to me, prior to signing this document. The Notice of Privacy Practices

describes the types of uses and disclosures of my protected health information that will occur in

my treatment, payment of my bills, and in the performance of health care operations of the

Ability Health Services. The Notice of Privacy Practices for Ability Health Services is also

posted at each office location and on the Ability Health Services website at

www.abilityrehabilitation.com This Notice of Privacy Practices also describes my rights and

Ability Health Services duties with respect to my protected health information. Ability Health

Services reserves the right to change the privacy practices that are described in the Notice of

Privacy Practices. I may obtain a revised notice of privacy practices by accessing the Ability

Health Services website, calling the office and requesting a revised copy be sent in the mail, or

asking for one at the time of my next appointment.

_________________________________ _______________________________ Date

Signature of Patient or Personal Representative

____________________________________ _______________________________ Personal Representative’s Authority

Print Name of Patient

I hereby authorize the release of my Protected Health Information to the following individuals

(Please Print NAME AND RELATIONSHIP):

______________________________________________________________________________

________________________________________________________________________

______________________________________________________________________________

OFFICE USE ONLY

I attempted to obtain the patients signature in acknowledgement on this Notice of Privacy

Practices Acknowledgement, but was unable to do so as documented below:

Date:

Initials: Reason:

REVISED 01.01.17

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will say “yes” to all reasonable requests.

Your Rights

Notice of Privacy Practices • Page 1

Your Information.Your Rights.Our Responsibilities.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.

continued on next page

Ability Health Services, Inc. Corporate Address:1200 Lexington Green Lane, Sanford, FL 32771 Phone:(407)688-0070 Fax:(407)688-0071 Website: www.abilityrehabilitation.com

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request, and we may say “no” if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.

• We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Notice of Privacy Practices • Page 2

Your Rights continued

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

• Include your information in a hospital directory

• Contact you for fundraising efforts

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In the case of fundraising: • We may contact you for fundraising efforts, but you can tell us not to contact you again.

Notice of Privacy Practices • Page 3

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you • We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

• We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

• We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

Our Uses and Disclosures

continued on next page

Notice of Privacy Practices • Page 4

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

• We can share health information about you for certain situations such as: • Preventing disease• Helping with product recalls• Reporting adverse reactions to medications• Reporting suspected abuse, neglect, or domestic violence• Preventing or reducing a serious threat to anyone’s health or safety

Do research • We can use or share your information for health research.

Comply with the law • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

• We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

• We can use or share health information about you:• For workers’ compensation claims• For law enforcement purposes or with a law enforcement official• With health oversight agencies for activities authorized by law• For special government functions such as military, national security,

and presidential protective services

Respond to lawsuits and legal actions

• We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Notice of Privacy Practices • Page 5

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of This NoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Our Responsibilities

This Notice of Privacy Practices applies to the following organizations.

Effective Date of Notice: October 01, 2014

This notice applies to all locations and entities owned and operated under Ability Health Services, Inc.

Privacy Officer, 1200 Lexington Green Lane, Sanford, FL 32771 (407)688-0070