Patient Terms and Agreement

Consent for Care

I hereby give my consent to Petkov Bodywork Therapy, LLC to provide care and services prescribed by my physician, both verbally and written. I also give my consent to exercise professional judgment in any additional care and services that may be necessary. My consent for care is extended to the said staff of the said agency providing occupational therapy. Instructions for my care are explained to me and I understand my obligation to follow the home program and any other recommendations given to me to the best of my ability.

I am also made aware that therapy services may result in one or all of the following: increased pain, increased swelling, increased redness, burning sensations and wound bleeding.

Assignment of Benefits

I Thereby authorize and direct my insurance carrier (including Medicare, private insurance and any other health/medical plan) to issue payment directly to Petkov Bodywork Therapy, LLC for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. It is my understanding that any money received over and above my indebtedness will be refunded to me when my bill is paid in full. I understand that I am responsible for any and all charges not covered by my insurance company any fees assigned by a collection agency or an attorney. A photocopy of this assignment is to be considered as valid as original. This will remain in effect until revoked by me in writing.

Authorization to Release Information

I hereby authorize Petkov Bodywork Therapy, LLC to (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used in processing insurance claims for the period of a lifetime. This order will remain in effect until revoked by me in writing. I have requested medical services from Petkov Bodywork Therapy, LLC. On behalf of myself and/or my dependents, and understand that my making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

Payment Policy

  1. Billing Insurance: It will be our pleasure to bill your insurance company for you, provided that you submit accurate billing information.
  2. Co-Pays: Co-pays are expected at the time of service, no exceptions. It is your contractual agreement with your insurance to pay your co-pay at the time of service.
  3. Coverage Changes: If your insurance changes please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you with payment expected within 30 days.
  4. Nonpayment: If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated, and then there will be a $10 rebilling fee for each additional monthly billing statement sent out to you. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency. You will be responsible for any collection fees incurred, and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30- days to find alternative medical care. During that 30 day period, our physician will only be able to treat you on an emergency basis
  5. Missed Appointments: Please notify us of a canceled appointment by 5:00 PM the prior day. Our policy is to charge a $50.00 fee for missed appointments. These charges will be your responsibility and billed directly to you.
  6. Payment: We offer a 15% discount for payment in full at time of service. We accept payment by cash, check, Visa or Mastercard.
  7. Policy Changes: This policy is effective beginning September 1, 2020, and may be revised as needed

  8. Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area.

    Thank you for understanding our payment policy. Please let us know if you have any questions or concerns. I have read and understand the payment policy and agree to abide by its guidelines.

Privacy Policy

At Petkov Bodywork Therapy, LLC we are committed to treating and using protected health information about you responsibly. This notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO), and for other purposes that are permitted or required by law. This Notice also describes your rights as they relate to your protected health information.

Understanding Your Health Record/Information

Each time you visit a hospital, physician, or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnosis, treatment, a plan for future care of treatment, and billing-related information. This information, often referred to as your health or medical record, serves as a:

  1. Basis for planning your care and treatment
  2. Means of communication among the many health professionals who contribute to your care
  3. Legal document describing the care you received
  4. Means by which you or a third-party payer can verify that serviced billed were actually provided
  5. A tool in educating health professionals
  6. A source of data for medical research
  7. A source of information for public health officials charged with improving health of this state and the nation
  8. A source of data for our planning and marketing
  9. A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

Understanding what is in your record and how your health information is used helps you to: ensure its accuracy; better understand who, what, when, where and why others may access your health information; and make more informed decisions when authorizing disclosure to others.

Our Duties and Responsibilities

We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices. We are required to comply with the terms of this Notice and reserve the right to change the terms of this notice. The revised or changed notice will be effective for information we already have about you, as well as any information we receive in the future. Petkov Bodywork Therapy, LLC is required to:

  1. Maintain the privacy of your health information
  2. Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
  3. Abide by the terms of this notice
  4. Notify you if we are unable to agree to a requested
  5. Accommodate reasonable requests you may have to communicate health information by alternative means or location

Uses and Disclosure

How we may use and disclose Health Information about you.

The following describe examples of the ways we use and disclose information about you.

For Treatment: We may use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination and management of your health care with a third party.

For example, we may disclose your protected health information, as necessary, to a home health agency that provides care for you. Your protected health information may also be provided to a physicians or hospital to which you have been referred to ensure that the physician or hospital has the necessary information to carry-out treatment, payment and health care operations. For Payment: We may use and disclose health information about your treatment and services to bill and collect payment from you, your insurance company, or third party. For example we may need to give your insurance company information about your office visit so they will pay us or reimburse you for the treatment. We may also tell your health plan about treatment you are going to receive to determine whether your plan will cover it.

For Health Care Operations: We may use and disclose, as needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. The result will then be used to continually improve the quality of care for all patients we serve. For example, we may combine health information about many patients to evaluate the need for new services or treatment. We may disclose information to doctors, nurses, and students for educational purposes. We may also combine health information we have with that of other health care facilities to see where we can make improvements. We may remove information that identifies you from this set of health information to protect your privacy.

We may also use and disclose health information:

  • To business associates we have contracted with to perform the agreed upon service and billing for it
  • To remind you that you have an appointment for medical care
  • To assess your satisfaction with our services
  • To tell you about possible treatment alternatives
  • To tell you about health-related benefits or services
  • To call upon you by name in the waiting room when your physician is ready to see you
  • To inform Funeral Directors consistent with applicable law
  • For population based activities relating to improving health or reducing health care cost
  • When disclosing information, primary appointment reminders and billing/collection efforts, we may - leave messages on your answering machine or voice mail.

Business Associates: There are some services we provide through contracts with business associates who work on our behalf. Examples include services in the emergency department, radiology, and laboratory tests. In such situations, we may disclose your health information so they can perform the job we ask them to do. We require all business associates to safeguard your information in accordance with applicable law.

Individuals Involved in Your Care or Payment for your Care: We may release health information about you to a family member or friend who is involved in your medical care or who helps pay for your care if submitted in writing. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

As Required by Law, we may also use and disclose health information for the following types of entities, including but not limited to:

  1. Food and Drug Administration
  2. Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability --Correctional Institutions
  3. Workers Compensations Agents
  4. Organ and Tissue Donation Organizations
  5. Military command Authorities
  6. Health oversight Agencies
  7. Funeral Directors, Coroners and Medical Directors
  8. National Security and Intelligence Agencies
  9. Protective Services for the President and Others

Law Enforcement / Legal Proceedings: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena Other permitted and required uses and disclosure will be made only with your consent, authorization or opportunity to object unless required by law.

Your Health Information Rights

Inspect and Copy: Upon written request, you have the right to inspect and obtain a copy of the health information that may be used to make decisions about your care. However, under federal law, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation or, use in, a civil, criminal, or administrative action or proceeding, and protecting health information that is subject to law that prohibits access to protected health information.

Amend: If you feel that health information we have about you is incorrect or incomplete, you have the right to request, in writing, that we amend the information. You have the right to amend your information as long as it is kept by and for the practice. We may deny your request for an amendment. If this occurs, you will be notified by our Privacy Officer of the reason for the denial.

Request Restrictions: You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purpose of treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or payment for your care, like a family member or friend. Your request must be submitted in writing, state the specific restriction requested, and to whom you want the restriction to apply. While we will consider any request, we are not required to agree. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected information will not be restricted.

Request Confidential Communication: You have the right to ask that we communicate with you by alternative means or at alternative locations. For example, you can ask that we contact you on your cell phone or ask us not to leave messages at your place of employment. The practice will grant any reasonable request for confidential communications at alternative locations and or via alternative means only if the request is submitted in writing and includes a current mailing address. Please realize, we reserve the right to contact you by other means or at other locations if you fail to respond to any communication from us that requires response.

A Paper Copy of this Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. An Accounting of Disclosure: You have the right to receive an accounting of certain disclosure we have made of any of your protected health information. Please contact the Privacy Officer at 951-3400 to request an accounting.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer, or with the Office of Civil Rights, US Dept. of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights.

Office for Civil Rights

US Dept. of Health and Human Services
200 Independence Ave SW
Room 509F, HHH Building Washington, DC 20201