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.
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.
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.
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.
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.
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:
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.
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:
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:
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:
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.
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