Intake & Treatment Agreement
Billing Address, if Different:
Consent to Text or Email
For Appointment Reminders or General Information
Patients in this practice may be contacted via e-mail and / or text messaging to be reminded of an appointment, to obtain feedback on their experience with this healthcare team, and / or to provide general health reminders / information.
I understand that this request to receive emails and text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing. The practice does not charge for this service, but standard text messaging rates may apply as provided in the patient’s wireless plan (contact cell carrier for pricing plans and details).
Appointment Times & Scheduling
All appointments are expected to last 40-60 minutes in length. BodyGoals Physical Therapy & Wellness will contact the patient or caregiver prior to, or the morning of the appointment to confirm appointment time. BodyGoals Physical Therapy & Wellness respects patient’s time and makes every effort to arrive on schedule. However, because an employee cannot anticipate what every person will need, or if medical emergencies arise, she will take whatever time is necessary to give each and every patient the best care that is needed. As BodyGoals employees makes home visits, one cannot foresee challenges in parking, heavy traffic, or unforeseen road conditions. For this reason therapists will give a window of two hours for appointment time of arrival. If therapist is running more than thirty minutes late then patient will be called and notified and given the opportunity to reschedule without a cancellation / no show fee.
Applies Only to Patients Outside Our Service Area
BodyGoals Physical Therapy & Wellness travels to treat patients in an area within Brookhaven, Roswell,Sandy Springs, Dunwoody, and Buckhead, Georgia. Whenever the schedule permits, a therapist will travel outside this area to service patients for an additional travel fee. At times, patients on the outskirts of this service area may qualify for the travel fee due to the distance from the therapist’s point of origin. BodyGoals Physical Therapy & Wellness therapists retain the right todecline admitting or treating patients who live outside the service area, or decline patients who live in conditions that are not suitable for therapy due to safety reasons.
Cancellations & Missed Visits
In the event that the patient is unable to keep an appointment please contact your therapist as quickly as possible. Visits that are cancelled less than 24 hours prior to visit time, or are not cancelled at all will be billed $75.00 due to scheduling and traveling inconveniences. E-mail is a suitable means to communicate visit cancelation. In the case of a true medical emergency, the cancellation fee will be waived.
I hereby consent to physical therapy treatment as prescribed by my physician, or as deemed necessary by the treating physical therapist. The patient is responsible for charges incurred, regardless of insurance coverage. If BodyGoals Physical Therapy & Wellness has a contract with the patient’s insurance carrier, BodyGoals will file the claim for patient’s services. If the insurance company denies payment for no referral, non-covered services, deductible, etc, I understand that I am responsible for all balances due. BodyGoals Physical Therapy & Wellness is a participating provider for Medicare B patients.
I understand, in some instances, all or some of the applicable physical therapy charges billed to my insurance company may not be covered under my insurance policy. I agree to be responsible for any portion of my bill not covered by insurance. I understand that it is my responsibility understand my insurance benefits and comply with the requirements of the policy.
Informed Consent to Treat
Physical, Occupational, and Speech Therapy involves the use of many different types of physical evaluation and treatment. The patient should understand that a Physical, Occupational and Speech Therapy diagnosis are not a medical diagnosis by a physician or based on radiological imaging and that health plan or insurer might not cover such services.
As with all forms of medical treatment, there are benefits and risks involved with physical therapy. Since the physical response to a specific treatment can vary widely from person to person, it is not always possible to accurately predict the patient’s response to a certain modality or procedure. It is impossible to predict an individual patient’s reaction to a particular treatment might be, nor can it be guaranteed that the treatment will help the condition the patient is seeking treatment for. There is also a small risk that the treatment may cause pain or injury, or may aggravate previous existing conditions. The patient has the right to ask the physical therapist what type of treatment she is planning based on medical history, diagnosis, symptoms and testing results. The patient may ask the therapist about the potential risks and benefits of a specific treatment. The patient has the right to decline any portion of the treatment at any time before or during the treatment session.
Therapeutic exercises are an integral part of most physical therapy treatment plans. Exercise has inherent physical risks associated with it. If the patient has any questions regarding the type of exercise that he/she is performing and any specific risks associated with these exercises, the therapist will be glad to answer them.
I acknowledge that a BodyGoals Physical Therapy & Wellness therapist has explained my treatment program, and all of my questions have been answered to my satisfaction. I understand the risks associated with a program of Physical, Occupational, or Speech Therapy as outlined to me, and wish to proceed.
Health Insurance Portability & Accountability Act of 1996 (HIPAA)
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
1. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
2. Obtain payment from third-party payers.
3. Conduct normal healthcare operations such as quality assessments and physician certifications.
I have been informed by by the agency of the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand thatBodyGoals Physical Therapy & Wellness has the right to change her Notice of Privacy Practices from time to time and that I may contact BodyGoals Physical Therapy & Wellness at any time to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that BodyGoals Physical Therapy & Wellness restricts how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand BodyGoals Physical Therapy & Wellness is not required to agree to my requested restrictions, but if the owner does agree than she is bound to abide by such restrictions.
I understand that I may revoke this consent in writing at any time, except to the extent that BodyGoals Physical Therapy & Wellness has taken action relying on this consent.
Acknowledgement of Provider Choice
I acknowledge that I have currently chosen BodyGoals Physical Therapy & Wellness, Inc to be my therapy provider. This decision is made with the awareness that there are other facilities that can provide these services, and I have the right to change providers or pursue my therapy at another facility. I have been educated by the admitting therapist that I am not required to choose BodyGoals Physical Therapy & Wellness, Inc for my therapy needs and I can request discharge at any point in my services.
Concerns & Complaints
If the patient is concerned that BodyGoals Physical Therapy & Wellness, Inc staff has violated privacy rights or if the patient or caregiver disagree with any decisions we have made please contact 470-416-9666 or firstname.lastname@example.org.
I have read and fully understand BodyGoals Physical Therapy & Wellness may use or disclose my personal health information, without limitations, for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided, patient trend studies 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 Anna Stromquist PT, DPT will consider requests for restriction on a case-by-case basis, but does not have to agree to requests for restrictions.
I hereby acknowledge to the use and disclosure of my personal health information for purposes as noted BodyGoals Physical Therapy & Wellness, the right to revoke this acknowledgement by notifying the practice in writing at any time.
Patient Media Release
BodyGoals Physical Therapy & Wellness therapists may request to take videos of patients to show their progress, or, to share photos of wounds to their surgical team.
I hereby grant permission to the staff of BodyGoals Physical Therapy & Wellness to use images, likenesses, audio or any other data (heretofore referred to as “Media”) obtained through my treatment for instructional, educational or research purposes. This included all photos, videos, audio recordings, charts, graphs, analysis or any other data obtained by or submitted to the staff of BodyGoals Physical Therapy & Wellness in the course of my treatment. The Media may be used in any professional manner that BodyGoals Physical Therapy & Wellness deems necessary and I understand that the Media belongs to BodyGoals Physical Therapy & Wellness and I will not receive any compensation or payment in connection to their use.
I assume the risks involved in releasing this information and release BodyGoals Physical Therapy & Wellness and it’s employees and contractors from any and all liability that could arise from the use of this Media.
Acknowledgement of COVID-19 Risk
And Agreement to Don Face Mask During Home Visits
I understand that I am opting for rehabilitation service/s which are not urgent.
I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that the staff of Magnolia Physical Therapy and wellness are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19.
However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with rehabilitation. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through these visits and wish to proceed.
I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test.
I understand that possible exposure to COVID-19 before/during/after my therapy may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death. In addition, after my elective treatment/procedure/surgery, I may need additional care that may require me to go to an emergency room or a hospital.
I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired treatment/therapy.
I also agree to inform my therapist if I develop any of the following symptoms : fever, general malaise, muscle weakness/pain, dry cough, difficulty breathing, pink eye,a positive COVID-19 test, or exposure to someone with COVID-19 in the past two weeks.
To protect my therapist from contracting or spreading COVID-19, I agree to don a face mask during home visits, and will request all present family members to don a face mask.
Signature of Agreement
I have truthfully answered all previous questions about Magnolia Physical Therapy and Wellness, Inc's policies, consent, and acknowledgements regarding my medical care.