Financial Policy s2

Consent to Treatment Medical Release Assignment of Benefits HIPPA Notification Cancellation/No Show Policy

Initials _____ Consent to Treatment: I hereby consent to evaluation and treatment by my physical therapist at Chesapeake Bay Aquatic & Physical Therapy (CBAY) _____ Medical Release: I hereby give permission to Chesapeake Bay Aquatic & Physical Therapy to release my medical information to my insurance company, physician, attorney, assignees, and/or beneficiaries. _____ Assignment of Benefits: I authorize payment of my insurance benefits directly to Chesapeake Bay Aquatic & Physical Therapy for all services I receive.

_____ HIPAA (Health Insurance Portability & Accountability Act: This authorizes that I have been given and read Chesapeake Bay Aquatic & Physical Therapy’s Notice of Privacy Practice Act.

Cancellation/No Show Policy: We ask that if you must cancel or re-schedule an appointment that you please give us at least 24 hours notice. A $20 fee will be accessed for all missed appointments without at least 24 hours notice. Insurance will not cover this charge. After your 3rd cancel or no show without 24 hours notice, you will be charged $20 and have the risk of being discharged from the practice.

_____ Late Arrivals: We respect the time of all our patients. We strive to stay on schedule so that you do not have to wait. If you are delayed and arrive late for your appointment, you may be asked to wait or reschedule your appointment.

_____ By signing below I state that I have read and/or been advised by the above policies of Chesapeake Bay Aquatic & Physical Therapy

Signature: ______Date: ______Financial Policy & Summary of Billing Procedures

Financial Policy Welcome to Chesapeake Bay Aquatic & Physical Therapy (CBAY)! Our staff is dedicated to providing quality care and will do our best to help you achieve your treatment goals. We believe that communication with our patients regarding our financial policy assists us in providing you with the best possible service. Please take the time to read the following and sign at the bottom of the page. Thank you! 1. CBAY staff will contact my insurance company and verify my physical therapy coverage. My insurance company will be billed as a courtesy, but this does not release me from financial responsibility for my account. Benefits given are not a guarantee of payment; they are dependent on your individual plan coverage. It is the patient’s responsibility to know and understand his/her coverage and benefits. You may also contact the member services department of your insurance to verify service(s) are covered. 2. Throughout my course of treatment, my insurance company will be billed daily. CBAY’s policy is to collect co-payments and co-insurances at the time of service. Some co-insurance estimates are based upon my insurance company’s current fee schedule and therefore are subject to change. This may result in a small balance due or refund due after all of my claims have been processed. 3. I will periodically receive a statement regarding my account. Please be sure we have your most current demographic and insurance information at all times. I will review my statement to ensure my insurance company is processing claims in a timely manner. 4. I am responsible for meeting my deductible, if applicable. I will be responsible for paying this amount before my insurance company will begin to pay. 5. Most insurance companies require either a prescription or referral. I am responsible for obtaining updated prescriptions and referrals. 6. If my account becomes delinquent, I understand that I may be contacted by phone in order to bring my account up to date. I also understand that if my account becomes 90 days past due, my account information may be sent to an attorney for collections. If your check is returned from the bank, you will be billed a $25.00 service charge. 7. I am responsible for notifying CBAY of any changes in my health or billing information. CBAY will make every effort to collect payment from my insurance company; however I understand that regardless of my account status, I am ultimately responsible for all the charges incurred for services rendered at CBAY to the extent the law allows. Summary of Billing Procedures  COMMERCIAL INSURANCE : I am responsible for my co-payment, co-insurance, and any outstanding deductible that may be due. CBAY will bill my insurance company and make every effort to collect on my claim. I remain responsible for any and all fees not paid by insurance, outside of contractual adjustments made by my insurance company.  WORKER’S COMPENSATION : I pay nothing out-of-pocket as long as my carrier pre-authorizes treatment.  MEDICARE : Medicare will pay for 80% of allowable charges after the $147 deductible for Part B services has been met. In 2008, Medicare has established a cap on physical therapy and speech and language pathology services. As a result, Medicare will only pay up to $1,940.00 for these services combined; $3700.00 if medically necessary and all services rendered above this limit will be the responsibility of me, the patient. As a courtesy to me, CBAY will bill my secondary insurance to recover the additional 20% and/or deductible. If I do not have secondary insurance or if they do not pay, I will be responsible for the additional 20%, and/or deductible. Medicare also requires my physician to certify a plan of care (POC) every 90 days. After my initial visit and every 90 days thereafter, CBAY will send a POC to my physician for his/her approval and signature. While CBAY will do their best to ensure they receive this from my physician, I am ultimately responsible to ensure proper authorization is obtained for my care. Failure of my physician to authorize care may result in Medicare denying payment thus shifting financial responsibility on to me.  MVA : CBAY will bill my automobile insurance for services rendered. If benefits become exhausted, CBAY will bill my primary health insurance. At that point, guidelines for commercial insurance, as stated above, will be followed. If I do not have medical insurance, I will be responsible for payment.  LITIGATION : If my treatment is related to an injury or accident that involves legal proceedings, CBAY’s policy is to not wait for settlement or payment. Therefore, I am responsible for payment at time of service.

Insurance Company: Effective Date:

Signature:______Date: ______Patient Name: ______DOB: ______

If Emergency Contact: ______Relationship: ______

Emergency Contact Ph#: ______Alternate Ph#: ______

Please list your past surgeries :

Please indicate if you have or had any of the following:  Cancer Please describe:______ Heart Problem When diagnosed: ______Controlled? Yes No  Diabetes Please describe: ______ Breathing problems Please describe: ______ Pacemaker  Headaches Please describe: ______ Osteoporosis  Arthritis Please describe: ______ Depression Please describe: ______ Seizures or Epilepsy Please describe: ______ HIV/AIDS When diagnosed: ______ Stroke  Allergies? Latex? Please describe: ______ Unexplained weight loss/gain How much? ______ Change in bowel/bladder control How so? ______ Difficulty sleeping  Recent falls  Dizziness  Currently Pregnant

Please list any other medical conditions here: ______

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Please list current medications if you have not provided us with a list: ______Policies and Procedures for Aquatic Therapy

Thank you for choosing Chesapeake Bay Aquatic & Physical Therapy for your aquatic therapy needs. In order to make your therapy sessions run as smoothly as possible, please review our policies and procedures below.

PLEASE: 1. Schedule or reschedule your appointments with our receptionists by phone or in person. Please verify with the receptionist you are scheduling within pool hours. 2. Enter through the main office and sign in before proceeding to the pool, even if you have a club membership. This procedure helps us to keep track of when you come to your appointments. 3. Once you sign in at the front desk, you may proceed to the pool. The aquatic therapist will usually be waiting in the pool area at your treatment time. 4. In order to make sure that you receive full treatment time, we ask that you arrive at your appointment early enough to sign in, change in the locker room (if needed) and enter the pool at your treatment time. Patients arriving early for appointment may be asked to wait to enter the pool. 5. Wear appropriate swimming attire (no cotton shirts or shorts allowed) for active exercises in the pool and please bring a towel with you at every appointment. 6. SportFit and the Health Department require everyone to shower off before entering the pool. 7. Please refrain from using deodorant, lotions or powders prior to entering the pool.

General Information: 1. You may place your valuables in one of the lockers in the locker rooms. You will be given instructions on how the locks work. 2. Aquatic therapy sessions will last approximately one hour unless stated otherwise by the therapist. 3. Open wounds or infections are NOT permitted in the water. Please let the aquatic therapist know if a wound or incision has changed in any way. 4. Bladder or Fecal Incontinence prohibits participation in Aquatic treatment. 5. Patient must exit pool at the end of treatment session. (SportFit members have access as their membership dictates.) 6. SportFit prohibits nonmembers from entering or exiting the pool without a therapist present. 7. Patients are prohibited from entering the Hot Tub or Main pool without approval from treating Therapist.

Please sign and date if you agree with the above conditions. Signature:______Date:______Chesapeake Bay Aquatic and Physical Therapy No Show/Cancellation Policy Effective December 1, 2016

What is our policy? All patients must call to reschedule or cancel their appointment PRIOR to 24 hours before their appointment is scheduled. A $20 fee will be assessed for all violations of this policy.

Furthermore, a patient will be taken off the schedule after their 2 nd no-show appointment or their 3 rd cancellation, regardless of timeliness of cancellation. If a patient would like to be put back on the schedule they must discuss with their primary PT to get approval. Why do we have this policy? CBAY wants the best possible outcome for all of our patients. In order for Physical Therapy to help, it must be applied on a regular, consistent basis. As Physical Therapists we have multiple courses of treatment we can use to assist you. However, in order for Physical Therapy to help, we need to see how our treatment plan, individually developed for you, is working. If you are not consistent with your appointments it is very difficult for us to determine the efficacy of our individualized treatment plan for you. If we determine our plan is not working after several weeks, we are able to alter our plan and try something different. We know that your time and money are valuable. We promise to give you the best of our abilities and equipment/resources in order for you to get the best possible outcome. We need you to partner with us in this endeavor. If you do not attend consistently, you will not get the best outcome and not get the most value out of your time and money. We are always willing to work with you and understand situations arise that are out of your control. Please keep in contact with your primary PT and let them understand so we can best work with you. We appreciate your understanding and compliance!

Bowie Laurel Severna Park Timonium Reisterstown 100 Whitemarsh Park Drive 13946 Baltimore Ave. 551-D Balt/Annap Blvd 2430 Broad Ave 2 Chartley Drive Bowie, MD 20715 Laurel, MD 20707 Severna Park, MD 21146 Timonium, MD 21093 Reisterstown, MD 21136 301-262-5852 301-498-2212 410-315-9080 410-308-3543 410-833-5300 301-262-3173 F 301-498-2213 F 410-315-9012 F 410-308-4663 F 410-833-5333 F