HIPPA and Consent For Treatment:
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. There are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services at www.hhs.gov. We have adopted the following policies: 1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information. 2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative. 3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA. 4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties. 5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or healthcare provider. 6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services. 7. We agree to provide patients with access to their records in accordance with state and federal laws. 8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient. 9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.
I hereby consent to, and authorize my physical therapist who may be involved in my care, to provide care and treatment prescribed by my physician and/or considered necessary or advisable by my physician, physical therapist or other healthcare professionals. I understand that a physical therapy diagnosis is not a medical diagnosis by a physician. I understand that it is my responsibility to inform my physical therapist or other health care professional if I experience any discomfort or pain during any treatment or if I have other unresolved concerns around my treatment. I understand that response to physical therapy intervention varies from person to person and it is possible that treatment may result in aggravation of existing symptoms or may cause pain or injury. This consent is intended as a waiver of liability for such treatment excepting acts of negligence.
Telehealth: Some patients may be eligible for treatments performed via telehealth, videoconferencing. We use the teleconferencing platform Zoom or Doxy, which is HIPAA compliant with end to end secure encryption. Options for telehealth treatment may be discussed with your physical therapist.
Access To And Release Of Health Information: I understand that Second Arrow may document medical and other information related to my treatment in electronic and other forms and that such information will be used in the course of my treatment, for payment purposes and to support those who are caring for me. I authorize my clinician(s) and The Second Arrow administrative staff to contact other healthcare professionals that may have information related to my prior and current health conditions and treatment.
Financial Policy: I understand that I am financially responsible for all charges to be paid prior to attending my appointment/s. I do hereby authorize Second Arrow to release all information necessary to secure the payment of said benefits.
I have been given an opportunity to ask questions, and all my questions have been answered to my satisfaction.
I confirm that I have read and fully understand this form.
In the event of a change in medical status, I understand that my treatment may be modified, stopped, or referred out to the proper practitioner.
I reserve the right to withdraw at any time.
E-mail/Texting/Voicemail Consent
At Second Arrow, we offer patients/parents/legal guardians the opportunity to communicate by e-mail, text messaging and voicemail. Using e-mail to discuss patient information, however, is different than phone messaging. Text messaging is not to be used to convey medical information or to discuss medical conditions unless it is secured. E-mail, text message and voicemail communication has a number of possible risks that patients/parents/legal guardians should consider.
Our dedicated team at Second Arrow will use reasonable means to protect the security and confidentiality of all e-mail, text message and voicemail information sent and received. We may contact you by telephone/voicemail to keep you informed for appointment reminders, medication adjustments, etc. Information may contain comprehensive medical information by either the phone number and/or email that you have provided below. This information may include demographic details (name, date of birth, address, etc.), specific medical details (diagnosis, medications, test results, etc.) and billing details.
If the patient/parent/legal guardian is worried about any information being seen by other people, or if the question or problem is urgent, then other form(s) of communication such as telephone communication should be used.
To reiterate, information can be sent on to other people, stored on a computer, or printed out on paper for storage. It can be sent out and received by many recipients. Information is easier to change than handwritten or signed documents. Information may be kept on computers/electronic devices even after the sender or the recipient believes they deleted his or her copy. Messages can occasionally be intercepted, changed, forwarded, or used without authorization or detection. Can be used to introduce viruses into computer systems. May be used as evidence in court.
By signing below, I acknowledge that I have read and fully understand the information the health care provider and/or practice has provided me regarding the risks associated with the communication of e-mail, text messages and voicemail between the provider and/or practice and me, and consent to the conditions outlined. In addition, I agree to the above instructions, as well as any other instructions that the health care provider and/or practice may impose regarding e-mail, text message and voicemail communications.
I consent to correspond with Second Arrow the following ways if needed: email, text, voicemail.
