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Welcome to Precision Physical Therapy & Fitness!

Precision Physical Therapy & Fitness

8030 Soquel Ave #200,
Santa Cruz, CA, 95062
(831) 464-8200

Welcome to Precision Physical Therapy & Fitness !( * mandatory to fill )

Thank you for choosing Precision Physical Therapy & Fitness! We have been providing quality rehabilitation and fitness services to Santa Cruz County since 2004. If you have tried physical therapy, massage therapy, hand therapy or fitness classes before, you will quickly discover that what we offer is as unique as each body that walks through our door.

 

INSURANCE AND BENEFITS

Any benefits information given to you by Precision's administrative team on behalf of a third-party payor is not a guarantee of payment. By signing below, you accept financial responsibility for all treatment received and understand all the benefits for physical therapy as outlined in your insurance plan. 

 

SPECIAL NOTICE FOR MEDICARE PATIENTS

Medicare Part B covers 80% of allowable charges for physical and occupational therapy for eligible patients. You are responsible for the remaining 20% of charges and your Medicare Part B annual deductible depending on your Medi-gap policy or secondary/tertiary coverage (if applicable).

Medicare will not cover outpatient physical or occupational therapy services if you are currently enrolled in home health care. Medicare has strict guidelines for covering physical therapy including requiring consistent, predictable progress, participation with program, and functional improvements.  Medicare sets limitations in total amount paid for physical therapy per year.  Your physical therapist is the best person with whom to speak with about these rules and how they apply to your rehabilitation.

 

CONSENT FOR TREATMENT

By electronically signing, you acknowledge and hereby agree and give your consent:

To medical treatment in relation to your physical condition. You authorize release of any medical documentation and personal health information needed to process your claim. 

You understand that you are responsible for any charges that are not paid by your insurance carrier. Furthermore, you understand that you are responsible to inform Precision's administrative staff of any changes that occur to your provided insurance policy throughout your treatment.

You authorize release of payment directly to Precision Physical Therapy & Fitness regardless of Precision's participation with your insurance (in or out of network). Should you default on your financial responsibility and collection action is necessary, you will be responsible for collection costs that are incurred. 

You understand that you are ultimately responsible for any charges incurred, even charges beyond what your insurance company deems medically necessary or if you exceed your benefit maximum. You understand that your insurance company may require a prescription, medical or administrative pre-authorization for treatment, or have reimbursement limits on physical therapy treatment that may prevent your insurance company from covering your treatment. If Precision is not provided with an initial prescription, and your insurance requires one to cover treatment, you understand you will be responsible for payment of services rendered even if you, as a member, were told otherwise by your insurer. You understand that you are responsible for knowing and meeting the requirements of your insurance provider and policy.

 

CONTACT INFORMATION

To provide feedback for our team, please contact our Experience Manager Angela Rovick (angela@prefitpt.com).
For account questions, please contact our Accounts Manager Nicola Souza (nicola@prefitpt.com).

 

Patient Details( * mandatory to fill )
PATIENT MEDICAL HISTORY( * mandatory to fill )

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PATIENT MEDICAL HISTORY( * mandatory to fill )
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  •  MRI
  •  X-Ray
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Notice of Privacy Practices Policy( * mandatory to fill )

Overview

Precision Physical Therapy & Fitness provides patients with a clear and concise explanation of their rights and our usage with respect to PHI. This clarification is provided via the Notice of Privacy Practice Document. Patients have the right to review this document and make an informed decision of how to proceed when receiving treatment.

 

Policy Statement

The objective of this policy is to provide workforce members with Precision Physical Therapy & Fitness legal duties, as well as the patient's rights and choices under the provisions of the Notice of Privacy Practices.

 

Scope

The policy applies to all workforce members, including medical staff, management, and others who have direct or indirect access to patient protected health information created, held or maintained by Precision Physical Therapy & Fitness, and its subsidiaries.

 

A. Providing the Notice of Privacy Practices

HIPAA Help Center has provided an address for the model of the Notice of Privacy Practice produced by the Department of Health and Human Services (HHS). Provide the appropriate Notice of Privacy Practice at the address below for all patients to review.

http://www.hhs.gov/ocr/privacy/hipaa/modelnotices.html

 

Policy

Individuals who receive health care services or items from Precision Physical Therapy & Fitness have the right to notice of the use and disclosures of PHI that are made by the organization, to know their rights with respect to PHI, Precision Physical Therapy & Fitness's legal duties with respect to PHI, as well as how and whom to submit complaints or request further information about Precision Physical Therapy & Fitness's Privacy Policies.

 

Procedure

1. Make the Notice of Privacy Practices available upon request to any person, even if the individual is not receiving services from the Precision Physical Therapy & Fitness.

2. Ensure that the Notice of Privacy Practices is provided to individuals who have a direct treatment relationship no later than the date that the health care service or items are provided to the individual in a transaction that involves ePHI.

a. If an emergency treatment situation, the Notice of Privacy Practices will be provided as soon as possible after the emergency as reasonably practicable.

3. Ensure that the Notice of Privacy Practices is at the service delivery site for individuals to request to take with them.

4. Prominently post the Notice of Privacy Practices where it is reasonable to expect individuals seeking health care services or items from Precision Physical Therapy and Fitness. Also make the notice available on the company website that provides information about customer service of benefits.

5. Provide the Notice of Privacy Practice to an individual by email if the individual has not withdrawn his/her agreement.

a. If it is known that the e-mail transmission has failed, provide a paper copy of the Notice of Privacy Practices to the individual.

6. Ensure that electronic notice automatically and contemporaneously with an individual's first request for service, if service is first provided to an individual electronically.

Note: Individuals who obtain an electronic copy of the Notice of Privacy Practices maintain the right to also receive a paper copy.

7. Make good faith efforts (unless in an indirect treatment situation) to obtain the patients signature no later than the date of the first delivery of health care services on the Patient Acknowledgement Consent Form indicating that they have read and received a copy of the Notice of Privacy Practices. This includes services that are delivered electronically.

8. Document any good faith attempts to obtain acknowledgement and the reason the acknowledgement was not obtained, in cases where the individual refuses to sign or otherwise fails to provide acknowledgement.

Note: Precision Physical Therapy and Fitness is not prohibited from providing treatment, or otherwise using or disclosing PHI as permitted by law if the individual does not sign an acknowledgment after having been asked to do so.

9. Retain a copy of each version of the Notice of Privacy Practices, acknowledgements of receipt, and documentation of good faith for acknowledgement not received for (6) years after the date when it was last in effect.

 

If a Health Plan:

1. Notice must be provided no later than the compliance date for the health plan, to individuals covered by the plan.

2. Thereafter, at the time of enrollment to individuals who are new enrollees.

3. No less than every three years, the health plan must notify individuals then covered by the plan of the availability of the notice and how to obtain the notice.

4. Notice must be provided to the individual who is named as the insured under the policy and one or more dependents (when applicable).

5. If the health plan has more than one notice, ensure that the notice provided is relevant to the individual or other party requesting the notice.

6. If there is a material change to the notice:

a. The health plan must post the change on its web site by the effective date of the material change to the notice, and provide the revised notice or information about the material change and how to obtain the revised notice, in its next annual mailing to individuals then covered by the plan.

b. When a health plan does not post its notice on a web site, revised notice or information about the material change and how to obtain the revised notice must be provided to individuals within 60 days of the revision.

B. Patient Rights

 

Policy

Precision Physical Therapy & Fitness complies with patient rights as they relate to PHI. Taking this into consideration, the organization has developed a standard method that includes, but is not limited to providing documentation, adjusting medical records, and communicating confidential information. The patient also maintains the right to file a complaint with the U. S. Department of Health and Human Services Office for Civil Rights when they feel that Precision Physical Therapy & Fitness has violated their rights.

 

Procedure

1.Provide the patient with a copy or summary of their health information within 30 days of their request. Apply any reasonable, cost-based fee.

2.Respond to patient requests to correct medical records.

a.If the answer is no, provide the patient with an explanation within 60 days.

3.Comply with reasonable patient requests to contact them in a specific way, or to send mail to a different address.

4.Respond to requests not to share certain health information for treatment, payment, or health care operations.

Note: Precision Physical Therapy & Fitness is not obligated to comply with all requests to not share the information referenced above.

a.If the patient (or individual on the patients behalf) pays for a service or health care item out of pocket in full, then comply with the request not to share PHI for the purpose of payment or operations with the patient's health insurer.

b.Otherwise, if not sharing the information would affect the patient's care, Precision Physical Therapy & Fitness may not comply with the request. Additionally, if the service or health care has not been paid for, then PHI may be disclosed for the purpose of payment or operations to the health insurer.

5.Provide the patient with a list of the times that PHI has been shared, dating back six years prior to the request date, when applicable.

a.The list may include who the information was shared with and why.

b.Include all the disclosures, except for those about treatment, payment and health care operations and certain other disclosures (such as any that the patient asked to make).

c.Provide one year of accounting for free, but charge a reasonable, cost-based fee for additionally accounting requested within the same year.

6.Provide the patient with a paper copy of the Notice of Privacy Practices.

7.Ensure that any party acting on the patient's behalf has the right to do  so.

Note: When the patient has given someone medical power of attorney or if someone is the patients legal guardian, that person can exercise the patients' rights and make choices about their health information.

 

C. Patient Choices

 

Policy 

Precision Physical Therapy & Fitness honors the patient's choice upon being advised how they wish for us to share certain health information. Once the patient's preference is made clear, PHI is only used in a manner that agrees with the patient's request.

 

Procedure

1. Comply with the patient's choice to: Share information with family, close friends, or others involved in their care. Share information in a disaster relief situation. Include the patient information in a hospital directory.

Note: In cases where the patient is incapacitated and cannot share their preference, Precision Physical Therapy & Fitness may share information that is felt to be in the best interest of the patient. Information may also be shared when it is needed to lessen a serious and imminent threat to health or safety.

2. In the cases below, PHI is never shared unless written permission is provided by the patient.

a. Marketing purposes

b. Sale of information

c. Most sharing of psychotherapy notes

3. We may contact the patient in fundraising efforts, however the patient has the choice to request that Precision Physical Therapy & Fitness not contact them again.

D. Uses and Disclosures

 

Policy

Precision Physical Therapy & Fitness may use or disclose PHI in order to provide treatment, bill for services, as well as business operations as long as a Patient Acknowledgement Consent Form has been signed by the patient.  In some cases, it is required that the patient provides their authorization to use and disclose PHI by signing a Use and Disclosure Authorization Form. However, in other instances, such as for the public good, public health and conditions of the law, PHI may be released without prior consent. In order to make the patient aware of the Uses and Disclosures of the PHI, this section of the Notice of Privacy Practice Form serves as a formal notification informing of how PHI may be used or disclosed. This policy may be used in conjunction with the following policies that detail the usage of PHI:

Uses and Disclosures for which the Opportunity to Agree or Object is Not Required Uses and Disclosures of PHI for Treatment, Payment and Health Care Operations

 

E.Health Care Provider Obligations

 

Policy

Precision Physical Therapy & Fitness maintains the privacy and security of PHI as required by the law. The organization is also obligated to adhere to the privacy practices as indicated in the Notice of Privacy Practices form. Additionally, information will not be used outside the purpose in which it was intended, and as authorized by the patient in writing. We uphold the patient's right to change their decision at any time with regard to use and disclosure. The Privacy or Security Officer will notify the patient in writing immediately if a breach occurs that may have compromised the privacy or security of PHI.

 

F. Revised Notices

 

Policy 

Precision Physical Therapy & Fitness reserves the right to make changes to the terms of the Notice of Privacy Practices. When a change has been made, the organization promptly changes and distributes the notice whenever there is a material change to the uses and disclosures, the individual's rights, the covered entity's legal duties, or other privacy practices stated in the notice.

 Individuals are provided with the updated Notice of Privacy Practices once the changes to the applicable processes have been made effective. 

 

References

164.520 Notice of Privacy Practices

164.512 Uses and Disclosures for Which the Opportunity to Agree of Object is not required

164.506 Uses and Disclosures to Carry Out Treatment, Payment and Heath Care Operations

 

Forms

Acknowledgement Consent Form

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Cancellation Policy( * mandatory to fill )

Due to the demand for appointments and the desire to provide all our clients the best access to our services, we require all clients who fail to cancel an appointment a full 24 hour prior to the start time of a scheduled appointment to be charged a cancellation fee. A late cancel of an appointment on Monday through Thursday results in a $50 cancellation fee.  A late cancel of an appointment on Friday and Saturday results in a $75 cancellation fee. If you fail to contact Precision at all prior to the appointment this fee increases to $100 for all days.

 

We understand that illnesses and emergencies happen and, even though this charge is automatically applied, you will have the opportunity to reverse it.

 

By electronically signing, I understand that I am responsible for all charges incurred because of this policy. 

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E-MAIL COMMUNICATION RELEASE FORM( * mandatory to fill )

I, the indicated electronic signatory, would like to communicate via e-mail with Precision Physical Therapy & Fitness staff on matters related to my health and/or my medical treatment. I understand that any Confidential Health Information that I send to the practice is not secure and is sent at my own risk. I will not hold the practice, nor any of its workforce members, liable for loss of any confidentiality associated with information transmitted via e-mail.

I also understand that it is not the policy of the practice to encrypt any Confidential Health Information I request to be sent to me via e-mail. Because this information is not encrypted I understand that it is not secure. I acknowledge this risk and will not hold the practice or any of its workforce members liable for any loss of confidentiality associated with such transmissions.

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Patient Portion Agreement( * mandatory to fill )

I, the undersigned, understand that while I am a patient at Precision Physical Therapy & Fitness:

● I am required to keep my (the patient or guarantor’s) account balance under $500.00 by

actively making payments towards it, OR be on a formal payment plan agreement with

Precision Physical Therapy & Fitness and be in compliance with the terms of that plan.

● If I am in breach the terms of this agreement, I will not be able to schedule future visits or

my future visits will be removed from the schedule until the terms of this agreement are

satisfied.

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