Today’s Date______Admission / Treatment Agreement

Consent to Medical and Related Health Care: I request and consent to the medical care and treatment procedures as determined necessary by my physician(s). I acknowledge the care I receive while in this facility is under the direction of my physician(s).

Medical and Allied Health Care Providers: I have been informed and understand that the Physical/ Occupational Therapist providing services to me in this facility are not independent contractors and are employees of this facility unless otherwise specifically identified.

Teaching Programs: I understand this facility may, from time to time, enter into agreements with academic medical and allied health programs. Because of these agreements, physical/occupational therapy students may participate in my care. I agree to participate in these programs, but have the right to limit my participation at any time.

Patient Rights: I acknowledge access to the Patient Rights information explaining my rights as a patient of this facility.

Personal Property: I have been informed and understand this facility will not be liable for any loss of my personal property unless it is inventoried and placed in a secured area maintained by this facility.

Payment for Medical and Related Care, Splints, and Durable Medical Equipment (DME): I agree to pay the charges incurred for the care I received as ordered by my physician(s) at this facility. I guarantee full payment of all charges unless restricted by Medicare. These charges include, but are not limited to if necessary, to stabilize and emergency medical condition. I also understand payment of Durable Medical Equipment is due the date of issue. I also agree to pay any copays and/or co-insurance charges at the time of service. There is a $28.50 fee for any and all returned checks.

In the event that I fail to pay these charges, I understand that I will be responsible for reasonable collection costs and attorney fees associated with the cost of resolving my account.

Assignment of Benefits: I hereby irrevocably assign and transfer to PTSSM any and all benefits either contractual, common law, or statutory, to which I am entitled or which are available to me under any medical, health, and accident or workers’ compensation policy, plan, or program. I hereby authorize and direct that nay such payments be paid directly to PTSSM. Should my insurance policy, or plan description, prohibit direct payment to providers, I direct to the Payor to issue the provider a check payable to PTSSM and myself. I further authorize and agree that a copy of this authorization shall be deemed valid as the original.

Cancellations or Late Arrivals: I understand, if possible, I will contact, PTSSM for cancellations or late arrival. I understand two (2) consecutive missed appointments without notification may result tin cancellation of all future appointments. I further understand if circumstances require my late arrival for the scheduled appointment, I may be asked to re-schedule.

I have read, understand and consent to the above agreement.

Patient Name Signature Date

If Patient is a minor:

I have read, understand and consent to the above agreement. Further, I give consent for treatment of the above named minor child By Physical Therapy Spine and Sports Medicine (PTSSM).

Parent/Legal Guardian Signature Date

Witness

Facility Employee Signature Date NOTICE OF PATIENT INFORMATION PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION. PLEASE REVIEW IT CAREFULLY.

Physical Therapy Spine and Sports Medicine (PTSSM) And ITS AFFILIATED OFFICE(S) LEGAL DUTY

PTSSM is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described herein.

USES AND DISCLOSURES OF HEALTH INFORMATION

PTSSM uses your personal health information primarily for treatment; obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example, PTSSM may use your personal health information to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you.

PTSSM may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law.

In any other situation, PTSSM policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time.

PTSSM may change its policy at any time. When changes are made, a new Notice of Patient Information Practices will be posted in the waiting room and patient exam areas and will be provided to you on your next visit. You may also request an updated copy of our Notice of Patient Information Practices at any time.

PATIENT’S INDIVIDUAL RIGHTS

You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes. All such requests must be made in writing to the affiliated office(s)’ Privacy Office or Office Manager.

You may also request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. PTSSM will consider all such requests on a case-by-case basis, but the PTSSM is not legally required to accept them.

CONCERNS AND COMPLAINTS

If you are concerned that PTSSM may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our Privacy Officer at the address listed below. You may also send a written complaint to the US Department of Health and Human Services. Further, PTSSM will not tolerate any retaliatory acts against employees or patients who file a complaint with the Department of Health and Human Services secretary, participate or testify in an investigation or verbally oppose any actions taken by Physical Therapy Spine and Sports Medicine that are unlawful under HIPAA Administrative Simplification.

For further information on the PTSSM health information practices or if you have a complaint, please contact the following person:

Scott Schuessler,DPT; Owner/Privacy Officer Physical Therapy Spine and Sports Medicine 15425 Manchester Rd Suite # 28 Ballwin, MO 63011 Telephone: 636.220.6969 Fax: 636.220.6973 HIPAA Patient Information Consent Form

Acknowledgement

I, the undersigned, acknowledge that I was provided a current copy of the PTSSM and/or its affiliated office(s)’ Notice of Patient Information Practices for my review.

I, the undersigned, have read and fully understand the PTSSM and/or its affiliated office(s)’ Notice of Patient Information Practices. I understand that the PTSSM and/or its affiliated office(s) may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I also understand that PTSSM and/or its affiliated office(s) will consider requests for restriction on a case-by-case basis, but does not have to agree to requests for restrictions.

I hereby consent to the use and disclosure of my personal health information for purposes as noted in PTSSM and/or its affiliated office(s)’ Notice of Patient Information practices. I understand that I retain the right to revoke this consent by notifying PTSSM and/or its affiliated office(s) in writing at any time.

______Patient Name

______Signature (Signature of Parent/Guardian) Facility Representative Signature

______Today’s Date Today’s Date

Consent of Release to Other Persons

I hereby give my consent for Physical Therapy Spine and Sports Medicine (PTSSM) and/or its affiliated office(s) to release information regarding my treatment /or healthcare and billing to the following persons:

______Name Relationship Phone

______Name Relationship Phone

DO NOT give out any information, even to family, unless specifically authorized to do so.

______Patient’s signature Today’s Date