Denver Physical Therapy at Home
1573 S. CATAWBA CIRCLE AURORA, CO 80018
TEL: (720)473-9791 FAX: (720) 500-5652

NOTICE OF PATIENT PRIVACY AND FINANCIAL AGREEMENT

We are committed to preserving the privacy of your personal health information. In fact, we are law to protect the privacy of your medical information and to provide you with Notice describing:

How medical information about you may be used and disclosed and how you can access this information.

We may require your written consent before we use or disclose to others your medical information for purposes of providing or arranging for your health care, the payment of the care that we provide to you, and the related administrative activities supporting your treatment.

We may be required by certain laws to use and disclose your medical information for other purposes without your consent or authorization.

As our patient, you have important rights relating to inspecting and copying your medical information that we maintain, amending or correcting that information, obtaining an accounting of our disclosures of your medical information, requesting that we communicate with you confidentially, requesting that we restrict certain uses and disclosures of your health information, and complaining if you think your rights have been violated.

We have available a detailed Notice of Privacy Practices which fully explains your rights and our obligations under the law. We may revise our Notice from time to time. You have the right to receive a copy of our most current Notice in effect. If you have not yet reserved a copy of our current Notice, please ask us and we will provide you with a copy. If you have any questions, concerns, or complaints about the Notice or your medical information, please contact us at the number above.

Release Of Medical Information Necessary to Process Claims: I give my consent for Denver Physical Therapy At Home to use and disclose protected health information about me to carry out treatment, payment, and health care operations. I also request payment of government benefits to the party who accepts assignment below. Although we will verify your benefits prior to treatment, the information provided to us by your insurance company is not a guarantee of payments. Your insurance company will determine it. Furthermore, I understand that Denver Physical Therapy At Home will prepare any necessary reports and forms to assist me in collections from the insurance company.

Cancellation Policy: We require 24 hours notice in the event of a cancellation. There is a $25.00 charge for a cancellation without proper notice. Your insurance will not cover the penalty amount and you will be responsible for this charge.

Assignment of Benefits / Consent for Physical Therapy: I, the undersigned due hereby agree and give my consent for Denver Physical Therapy At Home to furnish physical therapy services to myself or dependent, which is considered necessary and proper in evaluating and treating myself or dependent for my/their physical condition. I assign them all payments for medical services rendered. I acknowledge that they will bill my insurance company on my behalf. In the event medical payments are received directly by me for services rendered that have not been paid for, I promise to immediately sign over and forward those payments along with the Explanation of Benefits to Denver Physical Therapy At Home. I accept financial responsibility for all charges incurred. I understand that I am to pay any deductibles, co-payments, or other charges not covered by my insurance company. If my account has to be referred for outside collections, I will be charged a $30 service charge. For all returned checks, there is a $20 penalty in addition to the immediate cash payment for services rendered. I also authorize Denver Physical Therapy At Home to furnish any necessary information concerning injury/illness to the insurance carrier involved.

I accept financial responsibility for all charges incurred. I understand that I am to pay any deductibles, co-payments, or other charges not covered by my insurance company. If my account has to be referred for outside collections, I will be charged a $30 service charge. For all returned checks, there is a $20 penalty in addition to the immediate cash payment for services rendered. I also authorize Denver Physical Therapy At Home to furnish any necessary information concerning injury/illness to the insurance carrier involved.

NOTICE OF PRIVACY PRACTICES

WHO WILL FOLLOW THIS NOTICE

This notice describes the information privacy practices followed by our employees, staff, and other office personnel. The practices described in this notice will also be followed by health care providers you consult with by telephone who provide “call coverage” for your health care provider.

YOUR HEALTH INFORMATION 

This notice applies to the information and records we have about your health, health status, and the health care and services you receive at this office.We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, students, or other health system personnel who are involved in taking care of you in the health system. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. The doctor may use your medial history care for you. to decide what treatment is best for you. The doctor may also tell another doctor about your condition so that doctor can help determine the most appropriate treatment.

For Payment. We may use and disclose medical information about you so that the treatment and services you receive at home may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give information to your health plan about the specific physical therapy services you received so your health plan will pay us or reimburse you for the care. We may also tell your health plan about a proposed treatment to determine whether your plan will cover the treatment.

For Health Care Operations. We may use and disclose medical information about you in order to run the office and make sure you and other patients receive quality care. Your medical information may also be used and disclosed to comply with law and regulation, for contractual obligations, patients’ claims, grievances or lawsuits, health care contracting, legal services, business planning and development, business management and administration, underwriting, and other insurance activities and to operate the health system. For example, we may review medical information to find ways to improve treatment and services to our patients. We may also disclose information to doctors, nurses, technicians, medical and other students, and other health system personnel for performance improvement and educational purposes.

Appointment Reminders. We may contact you to remind you that you have an appointment for physical therapy.

Treatment Alternatives. We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health Related Benefits And Services. We may contact you about benefits or services that we provide.

Individuals Involved In Your Care Or Payment For Your Care. We may release medical information to anyone involved in your medical care, e.g., a friend, family member, personal representative, or any individual you identify. We may also give information to someone who helps to pay for your care. We may also tell your family or friends about your general condition and that you are in the hospital.

SPECIAL SITUATIONS

We may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements. As required by law, we will disclose information about you when required to do so by federal or state law.

To Avert A Serious Threat To Health Or Safety. We may use and disclose medical information about you when necessary to prevent or lessen a serious and imminent threat to your health and safety or the health and safety of the public or another person. Any disclosure would be to someone able to help or stop or reduce the threat.

Research. We may use and disclose health information about you for research projects that are subject to a special approval process. We will ask for your permission if the researcher will have access to your name, address, or other information that reveals who you are, or will be involved in your care at home.

Organ And Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement, eye or tissue transplantation, or to an organ donation bank, as necessary, to facilitate organ or tissue donation and transplantation.

Military and Veterans. If you are or were a member of armed forces, we may release medical information about you to military command authorities as authorized or required by law. We may also release medical information about foreign military personnel to the appropriate military authority as authorized or required by law.

Workers’ Compensation. We may use or disclose medical information about you for Workers’ Compensation or similar programs as authorized or required by law. These programs provide benefits for work-related injuries or illnesses.

Public Health Disclosures. We may disclose medical information about you for public health purposes. These purposes generally following:

  • Preventing or controlling disease (such as cancer or tuberculosis), injury or disability;
  • Reporting vital events such as births and deaths;
  • Reporting child abuse or neglect;
  • Reporting adverse events or surveillance related to food, medications or defects, or problems with products;
  • Notifying persons of recalls, repairs or replacements of products they may be using;
  • Notifying a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition;
  • Reporting to the employer the findings concerning a work-related illness or injury or workplace-related medical surveillance;
  • Notifying the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence and make this disclosure as authorized or required by law.

Health Oversight Activities. We may disclose medical information to governmental, licensing, and accrediting agencies as authorized or required by law.

Legal Proceedings. We may disclose medical information to courts, attorneys and court employees in the course of conservatorship and certain other judicial or administrative proceedings.

Lawsuits and Other Legal Actions. In connection with lawsuits or other legal proceedings, we may disclose medical information about you in response to a court of administrative order, or in response to a subpoena, discovery request, warrant, summons, or other lawful process.

  • Law Enforcement. If asked to do so by law enforcement, and as authorized or required by law, we may release medical information:
  • To identify or locate a suspect, fugitive, material witness, or missing person;
  • About a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
  • About a death suspected to be the result of a criminal conduct;
  • About criminal conduct at the office or home.
  • In case of a medical emergency, to report a crime; the location of the crime or victims’ or the identify, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may disclose medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine cause of death.

National Security and Intelligence Activities. As authorized or required by law, we may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities.

Protective Services for the President and Others. As authorized or required by law, we may disclose medical information about you to authorized federal officials so they may conduct special investigations or provide protection to the President, other authorized persons or foreign heads of state.

Information Not Personally Identifiable. We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.

  • E-mail can be circulated, forwarded, and stored in paper and electronic files.
  • E-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients.
  • E-mail senders can easily misaddress an e-mail.
  • E-mail is easier to falsify than handwritten or signed documents.
  • Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy.
  • Employers and on-line services have a right to archive and inspect e-mails transmitted through their systems.
  • E-mail can be intercepted, altered, forwarded, or used without authorization or detection.
  • E-mail can be used to introduce viruses into computer systems.
  1. CONDITIONS FOR THE USE OF EMAIL

DPTH will use reasonable means to protect the security and confidentiality of e-mail information to be sent and received. However, because of the risks outlined above, we cannot guarantee the security and confidentiality of e-mail communication, and will not be liable for improper disclosure of confidential information that is not caused by DPTH’s intentional misconduct.

Consent to the use of e-mail includes agreement with the following conditions:

  • DPTH may forward e-mails internally to our staff and agent necessary for diagnosis, treatment, reimbursement, and other handling, DPTH will not, however, forward e-mails to independent third parties without the patient’s prior written consent, except as authorize or required by law.
  • Although DPTH will endeavor to read and respond promptly to an e-mail from a patient, we cannot guarantee that any particular e-mail will be read and responded to within any particular period of time. Thus, the patient shall not use e-mail for medical emergencies or other time sensitive matters.
  • If the patient’s e-mail requires or invites a response from DPTH and the patient has not received a response within a reasonable time period, it is the patient’s responsibility to follow up to determine whether the intended recipient received the e-mail and when the recipient will respond.
  • The patient should not use e-mail for communication regarding sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.
  • The patient is responsible for informing DPTH of any types of information the patient does not want to be sent by e-mail, in addition to sensitive materials previously described.
  • The patient is responsible for protecting his/her password or other means of access to e-mail. DPTH is not liable for breaches of confidentiality caused by the patient or any third party.
  • DPTH shall not engage in e-mail communication that is unlawful, such as unlawfully practicing medicine across state lines.
  • It is the patient’s responsibility to follow up and/or schedule an appointment if warranted.
  • The patient must be 18 years or older or an emancipated or self-sufficient minor DPTH can send an e-mail about the patient.
  1. INSTRUCTIONS

To communicate by e-mail, the patient shall:

  • Inform DPTH of changes in his/her e-mail.
  • Put the patient’s name in the body of the e-mail.
  • Include the category of the communication in the e-mail’s subject line, for routing purposes (e.g. lab results).
  • Review the e-mail to make sure it is clear and that all relevant information is provided before sending to DPTH. Include a phone number at which the patient can be reached.
  • Take precautions to preserve the confidentiality of your e-mail.
  • Withdraw consent to use e-mail only by written communication to DPTH.
  1. PATIENT ACKNOWLEDGEMENT AND AGREEMENT

PATIENT ACKNOWLEDGEMENT AND AGREEMENT I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of e-mail between DPTH and me, and consent to the conditions herein. In addition, I agree to the instructions outlined herein, as well as any other instructions that DPTH may impose to communicate with patients by e-mail.

DPTH will use reasonable means to protect the security and confidentiality of e-mail information to be sent and received. However, because of the risks outlined above, we cannot guarantee the security and confidentiality of e-mail communication, and will not be liable for improper disclosure of confidential information that is not caused by DPTH’s intentional misconduct. Consent to the use of e-mail includes agreement with the following conditions: DPTH may forward e-mails internally to our staff and agent necessary for diagnosis, treatment, reimbursement, and other handling, DPTH will not, however, forward e-mails to independent third parties without the patient’s prior written consent, except as authorize or required by law. Although DPTH will endeavor to read and respond promptly to an e-mail from a patient, we cannot guarantee that any particular e-mail will be read and responded to within any particular period of time. Thus, the patient shall not use e-mail for medical emergencies or other time sensitive matters. If the patient’s e-mail requires or invites a response from DPTH and the patient has not received a response within a reasonable time period, it is the patient’s responsibility to follow up to determine whether the intended recipient received the e-mail and when the recipient will respond. The patient should not use e-mail for communication regarding sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse. The patient is responsible for informing DPTH of any types of information the patient does not want to be sent by e-mail, in addition to sensitive materials previously described. The patient is responsible for protecting his/her password or other means of access to e-mail. DPTH is not liable for breaches of confidentiality caused by the patient or any third party. DPTH shall not engage in e-mail communication that is unlawful, such as unlawfully practicing medicine across state lines. It is the patient’s responsibility to follow up and/or schedule an appointment if warranted. The patient must be 18 years or older or an emancipated or self-sufficient minor DPTH can send an e-mail about the patient.

INSTRUCTIONS To communicate by e-mail, the patient shall: Inform DPTH of changes in his/her e-mail. Put the patient’s name in the body of the e-mail. Include the category of the communication in the e-mail’s subject line, for routing purposes (e.g. lab results). Review the e-mail to make sure it is clear and that all relevant information is provided before sending to DPTH. Include a phone number at which the patient can be reached. Take precautions to preserve the confidentiality of your e-mail. Withdraw consent to use e-mail only by written communication to DPTH.

Picture and Video Consent Form

I authorize Denver Physical Therapy at Home to take pictures and/or videos of me for the purpose of marketing or advertising for the company. I acknowledge that they will be available to current patients, previous and part patients and the public weather that is online, social media platforms or printed. Denver Physical Therapy at Home can use these photos and videos until they are no longer needed. I understand that I will not be compensated and I have the right to decline and Denver Physical Therapy at Home can still treat me. If you wish to revoke your writing and give Denver Physical Therapy at Home the right to take pictures and/or videos, please contact email us at contact@denverphysicaltherapyathome.com.

I have read and understand this form. I authorize the use of my photos or videos for the purpose of marketing for Denver Physical Therapy at Home. I also understand that the recipient has no legal duty to protect its confidentiality and these photos and videos of me will be available for public.

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