1. Financial Policy
I hereby consent to physical therapy treatment as prescribed by my physician, or as deemed necessary by the treating physical therapist. I am responsible for charges incurred, regardless of insurance coverage. See rate sheet for current rates. If Move Free Physical Therapy at Home has a contract with my insurance carrier, Move Free will file the claim for your 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. Move Free Physical Therapy at Home accepts assignments for Medicare B patients and provides private pay services.
I understand, in some instances, some or all the applicable physical therapy charges billed to my insurance company may not be covered under my insurance policy. I understand that it is my responsibility understand my insurance benefits and comply with the requirements of the policy.
I agree to be responsible for any portion of my bill not covered by insurance.
2. Appointment Times and Scheduling
All appointments are expected to be approximately 60 minutes in length unless otherwise noted. You will receive an automated reminder prior to your appointment.
Move Free Physical Therapy at Home respects your time and makes every effort to arrive on schedule. However, because therapists cannot anticipate what every client will need, or in the case of medical emergency, they will take whatever time is needed to give each patient the care they need.
As Move Free therapists makes home visits, challenges in parking, heavy traffic, or unforeseen road conditions may also impact arrival time. For this reason, please allow therapists will give a window of 15 minutes before or after the appointment time of arrival. If therapist is running more than 15 minutes late then you will be called and notified and given the opportunity to reschedule without a cancellation / no show fee if needed.
3. Cancellation and No-Show Policy
If you are unable to keep an appointment please contact your therapist as soon as possible.
E-mail is a suitable means to communicate visit cancelation if the message is sent more than twenty-four hours prior to visit start time, otherwise please text or call the main number.
Late cancellation fees are as follows and will be billed directly to the client (not insurance)
Less than 24 hours’ notice: $25
Less than 4 hours’ notice or no-show: $50
The cancellation fee may be waived in case of true emergencies.
4. Informed Consent to Treatment
Physical Therapy involves the use of many different types of physical evaluation and treatment. Please understand that a Physical Therapy diagnosis is 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 between people, it is not always possible to accurately predict your response to a certain modality or procedure, and it cannot it be guaranteed that the treatment will help the condition you are seeking treatment for. There is also a small risk that the treatment may cause pain or injury or may aggravate previous existing conditions.
You have the right to ask the physical therapist what type of treatment they are planning based on medical history, diagnosis, symptoms and testing results. You may ask the therapist about the potential risks and benefits of any specific treatment. You have 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. Any exercise has inherent risks, so if you have any questions regarding the type of exercise that you will be performing and any specific risks associated with these exercises, the therapist will be glad to answer them.
I acknowledge that I understand my rights as a patient, that my therapist will explain my treatment program, and all my questions have been answered to my satisfaction. I understand the risks and benefits associated with a program of Physical Therapy, and consent to treatment.
5. Patient Privacy and 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 of the Notice of Privacy Practices (which can be downloaded here) 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 (see our website for most updated copy). I understand that Move Free Physical Therapy at Home has the right to change their Notice of Privacy Practices from time to time and that I may contact Move Free Physical Therapy at Home at any time to obtain a current copy of the Notice of Privacy Practices.
I fully understand that Move Free Physical Therapy at Home 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 Jessica Tomkoski 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 and permit the use and disclosure of my personal health information for purposes described above, and acknowledge my right to revoke this agreement by notifying the practice in writing at any time.
6. Consent to Email and Text messages
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.
If at any time you provide an e-mail or text address at which you may be contacted, You consent to receiving appointment reminders and other healthcare communications/information at that e-mail or text address from Move Free Physical Therapy at Home staff. You may revoke this consent in writing at any time.
We do 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).
7. Concerns and Complaints
If you are concerned that your therapist has violated privacy rights or if the patient or caregiver disagree with any decisions we have made, please contact Dr. Tomkoski, owner, 919-886-4163 or email@example.com. She will work with you to address your concerns and take appropriate action.