PATIENT’S CONTACT AND EMPLOYMENT INFORMATION
MM slash DD slash YYYY
INSURANCE CARD AND DRIVER'S LICENSE PHOTOS UPLOAD
Please upload a photo of the front of both your Insurance Card and your state-issued Driver's License. Please make sure both photos are clear and legible.
Accepted file types: jpg, jpeg, tif, png, Max. file size: 25 MB.
Accepted file types: jpg, jpeg, tif, png, Max. file size: 25 MB.
REFERRAL AND INJURY INFORMATION
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
POLICY HOLDER’S INFORMATION
MM slash DD slash YYYY
We are pleased to have you as our patient, and we are committed to providing you with our best professional care. Your clear understanding of our Financial Policy is important to our relationship . We want to ensure that we provide the appropriate services for your needs and that you are able to receive care with transparency surrounding the cost involved.
Please initial indicating that you have read and understand. If not applicable, please mark NA.
PPO/HMO/Commercial Plans: We will file your claims to your insurance provider. Copays, coinsurances
and deductibles are due at the time of service. Should your insurance provider need additional information
from you for the processing of our claim, it is your responsibility to assist by expediently providing the
necessary information to your insurance provider. It is in your best interest to assist your insurance provider
in obtaining all requisite information for their payment of your treatment, as you are ultimately responsible
for the payment of any amounts accrued for treatment. Please be aware of your coverage benefits for
physical therapy. It is ultimately your responsibility to be informed and to comply with the financial
obligations your insurance imposes. A benefits quote is not a guarantee of payment; it may be
subject to other plan limitations or exclusions.
- Veterans Affairs (VA) Benefits: We will file your claims to your insurance provider. VA plans have a limited number of authorized visits within an authorized date range. Should you exceed your plan’s terms, you may have to get reauthorization for continued care. Should your insurance provider need additional information from you for the processing of our claim, it is your responsibility to assist by expediently providing the necessary information to your insurance provider. It is in your best interest to assist your insurance provider in obtaining all requisite information for their payment of your treatment, as you are ultimately responsible for the payment of any amounts accrued for treatment. Please be aware of your coverage benefits for physical therapy. It is ultimately your responsibility to be informed and to comply with the financial obligations your insurance imposes. A benefits quote is not a guarantee of payment; it may be subject to other plan limitations or exclusions. It is also your responsibility for advising the clinic of any changes to your insurance plans at any point.
- State Insurance Plans: We will file your claims to your insurance provider. State plans have a limited number
of authorized visits within an authorized date range. Should you exceed your plan’s terms, you may have to
get reauthorization for continued care. Should your insurance provider need additional information from you
for the processing of our claim, it is your responsibility to assist by expediently providing the necessary
information to your insurance provider. It is in your best interest to assist your insurance provider in obtaining
all requisite information for their payment of your treatment, as you are ultimately responsible for the payment
of any amounts accrued for treatment. Please be aware of your coverage benefits for physical therapy.
It is ultimately your responsibility to be informed and to comply with the financial obligations your
insurance imposes. A benefits quote is not a guarantee of payment; it may be subject to other plan
limitations or exclusions.
- Self-Pay/Private Pay Patients: If you do not have insurance, or physical therapy benefits are not covered
by your insurance plan, we require payment in full at the time of service, unless prior payment
arrangements have been discussed. We accept cash, checks and all major credit cards.
- Personal Injury Protection: As a courtesy, we will file your claim to your insurance company. However,
you are ultimately responsible to see that the account is paid in full. Your insurance policy is an agreement
between you and your insurance company. Should the insurance need additional information from you for
the processing of our claim, we require that you assist in the prompt payment of the claim by expediently
providing the necessary information to your insurance company; otherwise the balance will be transferred
to your responsibility. It is your responsibility to research and notify our practice of your PIP limits as
such information is not made available to us. If our claims are denied due to maximum benefits being
exhausted, you will be responsible for the balance due. All statements sent to you will be 30 days from the
date of statement for payment in full unless prior payment arrangements have been discussed.
- Medicare: We are participating Medicare Providers, and do accept assignment from Medicare. Please advise
our office if you have secondary/tertiary insurance, so that we may file the claim to your secondary/tertiary
carrier for the remaining 20% coinsurance or deductible not payable by Medicare. You will receive a
statement showing any remaining balance owed by you once all insurance providers have processed and
paid/denied your claims. Per calendar year the Medicare Cap and Deductible are as follows. CAP: $2110.00 Deductible: $203. Approx: 25 Visits/year
- Workers Comp: Workers Compensation patients must provide the following before being seen by a physical
therapist: Claim Number, date of injury and name of adjustor. If your workers comp claim is denied, you
will be responsible for payment. If your claim is in litigation, you are responsible for payment. Upon
denial, please provide us with your health insurance information so that we can bill your health carrier, or
you may pay for services in full.
We accept CASH, CHECK and/or VISA/MASTERCARD/DISCOVER/AMERICAN
You may also apply payments on your account at any time through our secure website payment portal at www.accelacarept.com.
We reserve the right to refuse service for any reason, including but not limited to non-compliance in coming to therapy, acting disrespectfully to our staff and other patients or for unpaid balances. We reserve the right to require payment in full of unpaid balances before scheduling any subsequent appointments or services.
The following consent is a mutually agreed upon payment plan to account for unforeseen circumstances in which you may not be able to pay your balance in full within 90 days of your last date of service. This does not preclude you from making payments towards your balance during your ongoing plan of care and you are able to initiate a consistent payment plan before the 90 days if you so choose.
You may decline the option of a payment plan upfront. At the end of 90 days from your last date of service, if a balance remains, one of our front office team members will call to discuss monthly payment plan options. In this case you agree to set up a payment plan for an amount that matches your financial situation at that time and is mutually agreed upon.
A payment plan requires a card to be kept on file. The agreed upon amount will be applied to your card on the same date of your choice each month. We prefer to set a plan in which the balance is paid in full within 1 year of the initiation of the payment plan.
This agreement will remain in effect until Accelacare Physical Therapy has received written notification of changes at such time and in such manner as to afford Accelacare Physical Therapy a reasonable opportunity to open a discussion between both parties to alter the terms of this agreement.
Our billing department will make every attempt to work with you to resolve account balances. You will be notified of outstanding balances by receiving statements by mail. In the event that you no longer maintain financial responsibility towards your account and Accelacare has been unable to reach you to establish terms that are beneficial to both parties for repayment, we will notify you of your defaulted account by collection calls, and/or certified letters in hopes of initiating a payment plan. In the event we are unable to set up a payment plan we will turn your account over to a collection agency.
I acknowledge that I will be responsible for all reasonable costs associated with effectuating collection. If during the registration process I have provided a cell phone number; I acknowledge that I may be contacted at that number for account servicing matters, including but not limited to collecting on my account should it become delinquent.
- Cancellations/No Shows: All cancellations made without prior 24 hour notice or No Shows will be assessed
a fee of $25.00. Insurance does NOT cover late cancellation/no show fees; therefore, any fees due will be
collected from you on your next scheduled visit.
MM slash DD slash YYYY
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 this document carefully.
About Protected Health Information (PHI)
In this Notice, “we,” “our” or “us” means this Accelacare Physical Therapy and Occupational Services and our
workforce of employees, contractors and volunteers. “You” and “your” refers to each of our patients who are
entitled to a copy of this Notice.
We are required by federal and state law to protect the privacy of your health information. For example,
federal health information privacy regulations require us to protect information about you in the manner that
we describe here in this Notice. Certain types of health information may specifically identity you. Because we
must protect this health information, we call this Protected Health Information---or “PHI.” In this Notice, we tell
Some of the ways we use (within the organization) or disclose (outside of the organization) your
Protected Health Information
- How we use your PHI
- When we may disclose your PHI to others
- Your privacy rights and how to use them
- Our privacy duties
- Who to contact for more information or a complaint
We will use your PHI to treat you. We will use your PHI and disclose it to get paid for your care and related
services. We use or disclose your PHI for certain activities that we call “health care operations”. We will also
use or disclose your PHI as required or permitted by law. We will give you examples of each of these to help
explain them but space does not permit a complete list of all uses or disclosures. This is one reason why you
can contact us and ask us questions.
The above information is true to the best of my knowledge. I authorize my insurance benefits be
paid directly to Accelacare Physical Therapy. I also authorize Accelacare Physical Therapy or my
insurance provider to release any information required to process my claims.
We use and disclose your PHI in the course of your treatment. For instance, once we have completed
your evaluation or re-evaluation we send a copy or summary of our report to your referring physician.
We also maintain records detailing the care and services you receive at our facility so that we can be
accurate and consistent in carrying out that care in an optimal manner; that record also assists us in
meeting certain legal requirements. These records maybe used and/or disclosed by members of our
workforce to assure that proper and optimal care is rendered.
- Payment Involving a Third Party Payer
After we treat you we will, typically, bill a third party for services you received. We will collect the
treatment information and enter the data into our computer and then process a claim either on paper
or electronically. The claim form will detail your health problem, what treatments you received and it
will include other information such as your social security number, your insurance policy number and
other identifying pieces of information. The third party payer may also ask to see the records of your
care to make certain that the services were medically necessary. When we use and disclose your
information in this way is helps us to get paid for your care and treatment.
- Payment Exclusive of a Third Party Payer (fully self-pay)
If you choose to pay for your services, in full, without involving a third party (insurer, employer, etc.)
you may request that we do not disclose any information regarding your services for payment
- Health Care Operations
We also use and disclose your PHI in our health care operations. For example our therapists meet
periodically to study clinical records to monitor the quality of care at our facility. Your records and PHI
could be used in these quality assessments. Sometimes we participate in student internship programs
and we use the PHI of actual patients to test them on their skills and knowledge. Other operational
used may involve business planning and compliance monitoring or even the investigation and
resolution of a complaint.
- Special Uses
We also use or disclose your PHI for purposes that involve your relationship to us as a patient.
We may use or disclose your PHI to:
- Update your workers compensation case worker or employer
- Remind you of appointments
- Carry out follow ups on home programs that you have been taught
- Advise you of new or updated services or home supplies (you can choose to opt-out of receiving
any notices of this kind)
- Release equipment and/or supplies to your designee
- Carry out follow ups on your home programs or discharge planning
- Advise you of new or updated services or home supplies via telecommunication or via a
newsletter (you can choose to opt-out of receiving information of this nature from us)
- Carry out research that does not directly identify you
- Carry out marketing functions such as providing nominal promotional gifts (you can choose to
opt-out of receiving any marketing information or items from us)
- Contact you regarding fundraising projects that we are engaged in (you can choose to opt-out
of any fundraising project notification that we engage in)
Note: If we receive direct or indirect financial remuneration from a third party for marketing a product
or item or for any fundraising we are engaged in we will offer you the opportunity to ‘opt out’ from
receiving any of these materials.
- Uses & Disclosures Required or Permitted by Law
Many laws and regulation apply to us that affect your PHI, they may either require or permit us to use
or disclose your PHI. Here is a list from the federal health information privacy regulations describing
required or permitted uses and disclosures:
- If you do not verbally object, we may share some of your PHI with a family member or a friend
if he/she is involved in your care
- We may use your PHI in an emergency if you are not able to express yourself
- If we receive certain assurance that protect your privacy, we may use or disclose your PHI for
research; Accelacare Physical Therapy and Occupational Services will always obtain an
authorization from you even though it is ‘permitted’ without one.
- When required by law; for example, when ordered by a court to turn over certain types of your
PHI, we must do so
- For public health activities such as reporting a communicable disease or reporting an adverse
reaction to the Food and Drug Administration
- To report neglect, abuse or domestic violence
- To the government regulators or its agents to determine whether we comply with applicable
rules and regulations
- In judicial or administrative proceedings such as a response to a valid subpoena
- When properly requested by law enforcement officials or other legal requirements such as
reporting gunshot wounds
- To advert a health hazard or to respond to a threat to public safety such as an imminent crime
against another person
- Deemed necessary by appropriate military command authorities if you are in the Armed Forces
- In connection with certain types of organ donor programs
- Stricter Requirement That We Follow
Some state regulations are more stringent than federal privacy regulations so we comply with those
- Your Authorization May Be Required
In the situations noted above we have the right to use and disclose your PHI. In some situations,
however, we must ask for, and you must agree to give, a written authorization that has specific
instructions and limits on our use or disclosure of your PHI. If you change your mind, at a later date,
you may revoke your authorization.
- Your Privacy Rights and How to Exercise Them
You have specific rights under our federally required privacy program. Each of them is summarized
- Your Right to Request Limited Use or Disclosure
You have the right to request that we do not use or disclose your PHI in a particular way. However,
we are not required to abide by your request. If we do agree to your request we must abide by the
agreement; we have the right to ask for that request to be in writing and we will exercise that right.
- Your Right to Confidential Communication
You have the right to receive confidential communications from us at a location or phone number
that you specify. We have the right to ask for that request to be in writing noting the other address
or phone number and confirmation that it should not interfere with your method of payment; we will
exercise the right to have your request in writing.
- Your Right to Inspect and Copy Your PHI
You have the right to inspect and copy your PHI. If we maintain our records in paper, that will be
the format utilized; however if we maintain our records electronically you have the right to review
and/or have copies made in an electronic format. Should we decline we must provide you with a
resource person to assist you in the review of our refusal decision. We must respond to your
request within thirty (30) days, we may charge reasonable fees for copying and labor time related
to copying and we may require an appointment for record inspection; we have the right to ask for
your request in writing and will exercise that right.
- Your Right to Revoke Your Authorization
If you have granted us an authorization to use or disclose your PHI you may revoke at any time
it in writing. Please understand that we relied on the authority of your authorization prior to the
revocation and used or disclosed your PHI within its scope.
- Your Right to Amend Your PHI
You have a right to request an amendment of your record. We have the right to ask for the request
in writing and we will exercise that right. We may deny that request if the record is accurate and/or
if the record was not created by this facility. If we accept the amendment we must notify you and
make effort to notify others who have the original record.
- Your Right to Know Who Else Sees your PHI
You have the right to request an accounting of certain disclosure that we have made over the past
six years. We do not have to account for all disclosures, including those made directly to you,
those involving treatment, payment, health care operations, those to the family/friend involved
with your care and those involving national security. You have the right to request the accounting
annually. We have the right to ask for the request in writing and to charge for any accounting
requests that occur more than once per year; we must advise you of any charge and you have
the right to withdraw your request or to pay to proceed.
- You have a right to be informed of a breach your protected health information
We are required to notify the patient by first class mail or by e-mail (if indicated a preference to
receive information by e-mail), of any breaches of unsecured Protected Health Information as
soon as possible, but in any event, no later than sixty (60) days following the discovery of the
breach. “Unsecured Protected Health Information” is information that is not secured through the
use of a technology or methodology identified by the Secretary of the U.S. Department of Health
and Human Services to render the Protected Health Information unusable, unreadable, and
undecipherable to unauthorized users. The notice is required to include the following information:
- A description of the breach, including the date of the breach and the date of its discovery,
- A description of the type of unsecured protected health information involved in the breach
- Instructions regarding the measures the patient should take to protect him/her from potential
harm resulting from the breach
- Correction action Accelacare Physical Therapy and Occupational Services* has/will take to
investigate the breach, mitigate losses, and protect the patient from further breaches
- Accelacare Physical Therapy and Occupational Services* contact information, including a tollfree
telephone number, e-mail address, Web site or postal address for additional questions.
- You Have a Right to Complain
You have the right to complain if you feel your privacy rights have been violated. You may
complain directly to us by contacting our HIPAA officer noted in Section 10, or to 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 if you file a complaint about us. Your complaint should provide
a reasonable amount of specific detail to enable us to investigate your concern.
- The Patient Has the Right to Receive a Copy of the Privacy Notice
Accelacare Physical Therapy and Occupational Services* is obligated to provide the patient with
a copy of its Notice of Privacy Practices and to post the Notice in a conspicuous place for patients
to access as well as on our website. We have the right to change the Notice to comply with policy,
rules or regulatory changes; we are obligated to give new notices to current and subsequent
patients as changes are made. We are required to maintain each version of a Privacy Notice for
a minimum of six (6) years.
- Some of Our Privacy Obligations and How We Perform Them
If we change our Notice of Privacy Practices we will provide our revised Notice to you when you next
seek treatment from us.
- 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 that may have compromised the privacy or security of
- 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.
- Contact Information
If you have questions about this Notice, or if you have a complaint or concern, please contact:
Name: Accelacare Physical Therapy and Occupational Services
Address: 1800 Palace Drive. Suite C
Garden City, KS 67846
- Effective Date: This revised notice takes effect on June 20, 2016.
I understand that it is my responsibility to know my insurance benefits and whether or not the
services I am about to receive are covered benefits. I understand and agree that I will be financially
responsible for any cost-share or balance due that Accelacare Physical Therapy is unable to collect
from my insurance carrier due to any limitations on my plan coverage. If the account is in default and
turned over for collection, I acknowledge that I will be responsible for all reasonable costs associated
with effecting collection.
I have received the Notice of Privacy Practices and I have been provided an opportunity to review
it and I understand my rights as stated therein.
In addition, I authorize the release of information to the individuals/entities identified below by name
MM slash DD slash YYYY
MM slash DD slash YYYY