Excel Virtual Care Patient Packet

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XXX-XXX-XXXX

Address Line 1
Address Line 2






By providing my email address, I understand that authorized personnel from this physical therapy practice may communicate with me regarding scheduling, treatment, health educational and promotional information.









Street Address, City, State, and ZIP

















XXX-XXX-XXXX

Insurance Information





(Name of insurance policy owner)

(MM/DD/YYYY)




(Name of insurance policy owner)

(MM/DD/YYYY)




Medicare Secondary Payer (Only complete if you are enrolled with Medicare)
As a direct result of mandated Medicare Secondary Payer (MSP) regulations, we are required to gather the following information to determine if Medicare is your primary insurance.










Patient Health Questionnaire




















Consent and Statement of Financial Responsibility

I hereby consent to the use and disclosure of my health information for treatment provided to me by this physical therapy practice, payment for services provided by the provider or other health care providers and the operations of this physical therapy practice and others under certain circumstances. I understand that a more detailed explanation of the ways this physical therapy practice may use and disclose my health information is contained in the Notice of Privacy Practices of the Provider, a copy of which has been provided to me.
PATIENT CODE OF CONDUCT

It is our goal to provide the highest quality of care in a safe environment. In our efforts to achieve this goal, we require all patients and visitors to refrain from any behavior that may pose a threat to the rights or safety of other patients and employees. Our patients agree to refrain from the following actions: (1) Bringing firearms or other weapons into the clinic; (2) Inappropriate behavior involving alcohol/substance use at time of treatment; (3) Attempting to intimidate or harass in any manner therapists, staff, or fellow patients; (4) Inappropriately touching therapists, staff, or fellow patients; (5) Racial or cultural slurs or other derogatory remarks associated with, but not limited to, race, language or sexuality; (6) Making verbal threats to harm another individual or destroy property through any medium of communication; and (7) Physical assault or inflicting bodily harm. Violators of the abovementioned actions may be asked to leave the facility and/or be discharged from the clinic. My signature below indicates that I will support the clinic in its efforts to provide me with quality care in a safe environment and that I understand and accept the terms of the Patient Code of Conduct.


CONSENT FOR TREATMENT

I hereby consent to physical or occupational therapy services deemed medically necessary by my therapist and other health care professional involved in my care. I understand that my physical therapy program may include remote therapeutic monitoring (RTM). RTM services include telephone or video communications from a clinician to review my progress between ​in-clinic visits. This communication will allow my therapy team to monitor my progress and adjust my home exercise program as necessary to achieve my rehabilitation goals. I will receive complimentary access to the MedBridgeGo©​ software as well as education to use the app throughout my course of care.


CANCELLATION AND NO SHOW POLICY
Patients are expected to keep all scheduled appointments to maximize the benefits of their treatment plan. If a patient is unable to make a scheduled appointment, the patient is expected to give 24 hours advance notice or may be charged a cancellation fee of $60. Two (2) consecutive appointment no-shows may result in discontinuation of the current appointment schedule for the therapy involved. A pattern of frequent absences (cancellation and/or no-shows) will be considered problematic and result in discontinuation of services. 

TELEPHONE CONSUMER PROTECTION ACT NOTICE
You expressly consent and agree that, in order to discuss or provide services for your account(s) (the "Accounts") or to collect amounts you may owe, this Physical Therapy Practice, and its officers, agents, affiliates, employees, first and third party debt collection agencies, and any affiliated or business associated service providers or vendors of any of these parties,  associated therewith (collectively, "We") may contact you by telephone at any telephone number associated with the Accounts, including wireless telephone numbers, which could result in charges to you.  You confirm that any telephone number provide is associated with you and not a third-party.  You expressly consent and agree that We may also utilize your information to contact you by letters or notices via mail, by sending emails, using any e-mail address you provide to us, by sending text messages or by pre-recorded or artificial voice or voice messages, via predictive or automatic dialing methods, systems, or devices, and pre-recorded or artificial voice announcements or prompts at any telephone number associated with the Accounts, including landlines, wireless or mobile telephone numbers, regardless of whether you incur charges as a result.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
You may access a copy of the Notice of Privacy Practices upon request or by downloading on the company website.

CONSENT TO PARTICIPATE IN TELEHEALTH SERVICES

  • PURPOSE. The purpose of this form is to obtain your consent for a telehealth interaction with a physical therapist. 

  • NATURE OF TELEHEALTH CONSULTATION. Telehealth involves the use of audio, video or other electronic communications to interact with you, consult with your healthcare provider and/or review your medical information for the purpose of diagnosis, therapy, follow-up and/or education. During your telehealth consultation, details of your medical history and personal health information may be discussed with other health professionals using interactive video, audio and telecommunications technology. Additionally, a physical examination of you may take place and video, audio, and/or photo recordings may be taken. 

  • RISKS, BENEFITS AND ALTERNATIVES. The benefits of telehealth include having access to physical therapy services and additional medical information and education without having to travel outside of your home. A potential risk of telehealth is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telehealth appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telehealth consultation is a face-to-face visit with a physical therapist. 

  • MEDICAL INFORMATION AND RECORDS. All laws concerning patient access to medical records and copies of medical records apply to telehealth. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without your consent. 

  • CONFIDENTIALITY. All existing confidentiality protections under federal and state law apply to information used or disclosed during your telehealth consultation.

  • RIGHTS. You may withhold or withdraw your consent to a telehealth consultation at any time before and/or during the consult without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. 


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