NEW PATIENT INFORMATION
CONSENT TO TREAT
This form is an important legal document. It explains the risks you are assuming by participation in physical therapy and personal training activities. It is important that you read and understand it completely. After you have done so, please accept this policy to proceed.
Waiver, Informed Consent, and Covenant Not to Sue
By accepting this policy, I have registered to participate in physical therapy, personal training, and/or running motion analysis under the direction of Omega Project PT LLC, which will include, but may not be limited to manual therapy, dry needling, modalities, running and exercise interventions. In consideration of the Omega Project PT LLC’s agreement to assess, treat, and assist me, I do here and forever release and discharge and hereby hold harmless Omega Project PT LLC, and their respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation. THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF (1) EQUIPMENT THAT MAY MALFUNCTION OR BREAK (2) ANY SLIP, FALL, DROPPING OF EQUIPMENT AND (3) OUR NEGLIGENT INSTRUCTION OR SUPERVISION.
Assumption of Risk
By accepting this policy, I recognize that physical therapy, exercise and running techniques may be difficult and that there could be dangers inherent for some individuals. I acknowledge that the possibility of certain unusual physical changes during these do exist. These changes include abnormal blood pressure; fainting; disorders in heartbeat; heart attack; and, in rare instances, death. I understand that as a result of my participation, I could suffer an injury or physical disorder. I recognize that it is my responsibility to notify Omega Project PT LLCC if I have experienced any medical issues that may place me at risk for injury or create an unsafe environment. This may include, but is not limited to, pregnancy, high blood pressure, and orthopedic impairments. I may decline participation in any activity that may be unsafe or I am not comfortable. I acknowledge and agree that I assume the risks associated with any and all activities and/or exercises in which I participate. I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST ACE Running, LLC, or OTHERS REFERRED TO IN THIS DOCUMENT FOR ANY NEGLIGENCE OR THAT OF OUR EMPLOYEES, AGENTS, OR CONTRACTORS.
NOTICE OF PRIVACY PRACTICES
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.
The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information.
As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your information. We may use and disclosed your medical records only for each of the following purposes: treatment, payment and health care operations.
Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination.
Payment means such activities as obtained reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.
We may also create and distribute de-identified health information by removing all references to individually identifiable information.
We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
The right to inspect and copy your protected health information.
The right to amend your protected health information.
The right to receive an accounting of disclosures of protected health information.
The right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.
This notice is effective as of July 31st, 2018 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.
You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.
Please contact us for more information. Omega Project PT
1806 Van Buren St Suite 100 Wilmington, DE 19802
For more information about HIPAA or to file a complaint:
The U.S. Department of Health & Human Services Office of Civil Rights
200 Independence Avenue, S.W. Washington, D.C. 20201
Toll Free: 1-877-696-6775
All cancellations need to be made 24 hours prior to your appointment.
If you do not show up for your appointment or cancel with-in 24 hours, you will be responsible to pay for 100% of the session.
Payment is due at the time of service. It is your responsibility to make sure you are aware of the cost of your visit before you begin your treatment.
We are not contracted with any insurance companies. However, the payments you make may be reimbursable by your insurance company under your out of network physical therapy benefits; the exact percentage depends upon your plan. A guide for calling your insurance company has been provided on our website (insurance & payment). Due to the complex nature of insurance claims and reimbursement, we make no promises as to whether you will receive reimbursement.
We will assist you in every way possible. Payment is due at the time of service.
STATEMENT ON MEDICARE
Omega Project PT, LLC is not an enrolled provider with Medicare or any other form of health insurance.
Services rendered in our practice are not covered by Medicare or your Secondary Insurance.
If you would like Physical Therapy to be covered by insurance or Medicare and if you have a Physician referral for such, we will be happy to recommend other providers to you who are in- network with your health plan or are enrolled providers with Medicare.
If you are unwavering, however, in your desire to be seen by Brianne Scott or Doug Adams for their expertise, we ask that you agree that you understand that you will be paying privately for your services even if your services might be covered by your insurance or Medicare if the services were provided by an in-network or Medicare enrolled provider. You also understand that you cannot receive reimbursement from Medicare or a
Medicare secondary insurance plan.
Brianne Scott and Doug Adams do not believe in discrimination against clients who are 65 and over (i.e., Medicare eligible) by turning them away if they wish to be seen by them, even though they have been given and considered other options that might be covered by insurance. They would like to help you and are willing to assess your problem and administer the necessary number of treatments and to provide wellness advice, preventative and fitness exercises.
We would be happy to answer any questions you have regarding this matter. Thank you for understanding.
I understand that Brianne Scott and Doug Adams will not submit claims to Medicare or Secondary Insurance Providers on my behalf or provide me with a statement or billing codes that I can submit to Medicare or Secondary Insurance Providers myself. I understand that if I want Medicare or Secondary Insurance Providers to pay for any services that might be considered covered benefits, I should seek those services from a Medicare enrolled provider. By choosing to receive services from Brianne Scott and Doug Adams after being fully informed of these facts, I am agreeing to pay privately for the services I receive from Brianne Scott and Doug Adams even if those services might be covered by Medicare if provided by a Medicare enrolled provider. I also understand that since Brianne Scott and Doug Adams are not enrolled as a Medicare provider and the services provided do not meet the technical requirements for Medicare covered benefits, these services are not subject to Medicare’s maximum allowable charge. I agree that I, my caregivers, family members, authorized representatives or power of attorney will not, under any circumstance, submit my claims, invoices, receipts or statements to Medicare or my Medicare Advantage Plan for reimbursement or to obtain a denial for a Medicare supplemental insurance plan.
I acknowledge, under my own free will and accord, that I would like to restrict disclosure of my protected health information (PHI) to my health plan for the purposes of payment pursuant to my rights under HIPAA because I have paid for my services privately at the time of service