Physical therapy is a patient care service that is provided in order to manage a wide variety of conditions. Services are provided to individuals of all ages regardless of gender, color, ethnicity, creed, national origin, or disability.

The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis and intervention by use of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum physical potential within their capabilities. All procedures will be thoroughly explained to you before you are asked to perform or receive them. Response to physical therapy intervention varies from person to person; hence, it is not possible to accurately predict your response to a specific modality, procedure, or exercise protocol. Balanced Body Rehab, LLC does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for. Furthermore, there is a possibility that the physical therapy treatment may result in aggravation of existing symptoms and may cause pain or injury. It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns. It is your right to ask your physical therapist about the treatment they have planned based on your individual history, physical therapy diagnosis, symptoms, and examination results. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment.

I have read this consent form and understand the risks involved in physical therapy and agree to fully cooperate, participate in all physical therapy procedures, and comply with the established plan of care. I authorize the release of my medical information to appropriate third parties

24 Hour Cancellation Policy: Please provide 24 hour notice in order to reschedule or cancel your appointment. Note that your appointment time is reserved specifically for you; hence, late cancellations without valid reason will be charged 50% of your session amount.

Medicare 24 Hour Cancellation Policy: Please provide 24 hour notice in order to reschedule or cancel your appointment. Note that your appointment time is reserved specifically for you; hence, late cancellations without valid reason will be charged $25 per half hour session.

No Show Policy: Any established patient who fails to show at their appointment will be charged 100% of your session visit without valid reason.

Billing: All patients will receive a Balanced Body Rehab receipt with each payment. If you would like a more detailed receipt for your records or to submit to your insurance company, please let your physical therapist know or contact our front office at (314) 780- 9759 or info@balancedbodyrehab.com.

Balanced body rehab is a participating provider with Medicare Part B. Balance Body Rehab is currently out of network with all other private plans Including, but not limited to, Medicare Complete and Medicare Advantage plans, also known as Part C). Balanced Body Rehab does our best to verify that patients are within the network in order to receive Medicare benefits. However, it is ultimately the patient’s responsibility to verify their Medicare benefits prior to initiating treatment.

Medicare covers 80% of all physical therapy services billed. The remaining 20% will be billed to your supplemental insurance plan, if applicable. In some instances, the supplemental insurance plan may deny reimbursement to Balanced Body Rehab or provide partial reimbursement. Any amount not covered by the supplemental plan will become patient responsibility.

You should reach out to your carrier when you initiate care here to familiarize yourself with the limits of your policy and what will and will not be covered. We do our best to guide patients through this process, but we ask that patients be responsible for understanding the provisions, limits, and requirements of their individual benefit plan(s) and advise us accordingly.

Please bring/have your insurance cards with you at each visit and notify our staff of any changes in your coverage. Financial problems should not be a deterrent to obtain medicare. If you require special arrangements, please speak to the office personnel.

Trigger point dry needling (also known as intramuscular manual therapy/IMT) is an invasive procedure using a solid filament needle to penetrate the skin in order to reach a myofascial trigger point within the muscle (Trigger points: taut bands within a muscle that my cause local and referred pain as well as limit movement). Dry needling is NOT acupuncture. It utilizes the anatomical landmarks of the body to locate and treat trigger points, relieving a person’s pain and improving overall function.

Physical therapists who utilize dry needling as part of their physical therapy practice have received extensive training for the appropriate technique and use of dry needling in conjunction with other manual therapy techniques. They are not licensed acupuncturists, but rather can perform dry needling after appropriate training because it is within the scope of physical therapy practice.

BENEFITS:

• Decreased pain both locally and into referral sites
• Improved muscle function (able to contract and relax appropriately)
• Improved ability to move and function for daily activities
• Decreased muscular tension and improved myofascial flexibility

RISKS:

• Muscle soreness or bruising at/near the needling site; typically, 1.5 hour to 2 days
• Pneumothorax if needling around/near chest wall; extra precautions also taken in these areas
• Minor bleeding from superficial vessels

On occasion, Balanced Body Rehab will have an opportunity to promote our services and programs. Such promotions will be in the form of media and marketing. Since we cannot photograph, video or audio tape, or write articles about our clients without obtaining their permission, we must receive a written Media/Public Relations Authorization. This is voluntary and the organization will not and cannot require you to sign it. By agreeing and signing the Media/Public Relations Authorization form below, you will give Balanced Body Rehab permission to photograph, video or audio tape, or write articles about you.

I authorize Balanced Body Rehab to disclose to media representatives and/or public affairs staff members my protected health information including my condition and/or reason for treatment for purposes of publicity, promotion, education or publication in print, broadcast and electronic and social media. This authorization includes my likeness on photo, videotape and digital media.

1. I authorize Balanced Body Rehab to disclose to media representatives and/or public affairs staff members protected health information and information about me, my condition or treatment for purposes of publicity, promotion, education or publication in print, broadcast and electronic and social media. This authorization includes my likeness on photo, videotape and digital media.
2. I understand that once my protected health information is used and/or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient(s).
3. I understand that I have the right to revoke this authorization at any time. My revocation must be in writing as described in the Notice of Privacy Practices. I understand that such revocation shall be effective for future uses and disclosures, but such revocation shall
4. not be effective for information already used or disclosed. I understand that once my health information is used or disclosed, it is no longer protected by state or federal law
5. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from Balanced Body Rehab nor will it affect my eligibility for benefits.
6. I understand that I have a right to inspect and copy my own protected health information to be used or disclosed in accordance with the Notice of Privacy Practices.
7. I understand that I will not be compensated in any way for the taking or use of photographs, films, audio and/or videotapes, or the publishing of any article or information.
8. I understand that I may revoke this Authorization at any time by notifying Balanced Body Rehab at 314-780-9759 via a phone call or in writing to info@balancedbodyrehab.com, but if I do, it will not have any effect on any actions Balanced Body took before it received the revocation.
9. I understand that there is potential for information disclosed based on this authorization to be subject to re-disclosure by the recipient and no longer be protected by the Privacy Rule

I have read and agree to the Terms and Conditions outlined in the Media/Public Relations Authorization for the Use and Disclosure of Protected Health Information

5. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from Balanced Body Rehab nor will it affect my eligibility for benefits.

6.I understand that I have a right to inspect and copy my own protected health information

to be used or disclosed in accordance with the Notice of Privacy Practices. 7. I understand that I will not be compensated in any way for the taking or use of photographs, films, audio and/or videotapes, or the publishing of any article or

8. I understand that I may revoke this Authorization at any time by notifying Balanced Body Rehab at 314-780-9759 via a phone call or in writing to info@balancedbodyrehab.com but if I do, it will not have any effect on any actions Balanced Body took before it

9. I understand that there is potential for information disclosed based on this authorization to be subject to re- disclosure by the recipient and no longer be protected by the Privacy

I have read and agree to the Terms and Conditions outlined in the Media/Public Relations

Authorization for the Use and Disclosure of Protected Health Information

Balanced Body Rehab’s policies and federal regulations protect the privacy of our patients’ health information. The Health Insurance Portability and Accountability Act (HIPAA) is a set of federal rules that define what information is protected, sets limits on how that information may be used or shared, and provides patients with certain rights regarding their information. Balanced Body Rehab has its own policies that reflect these regulations as well as best ethical standards.

These rules protect information that is collected or maintained, (verbally, in paper, or electronic format) that can be linked back to an individual patient and is related to his or her health, the provision of health care services, or the payment for health care services. This includes, but is not limited to, clinical information, billing and financial information, and demographic/scheduling information. Even the fact that an individual has received care at Balanced Body Rehab is protected by our own policy and federal regulations.

Balanced Body Rehab’s policies and HIPAA regulations limit the use or sharing of protected patient information to the following purposes: providing treatment, obtaining payment for services, certain health care administrative functions and when required or permitted by law. Any other use or disclosure of protected information requires written authorization from the patient. For all uses or disclosures other than treatment, only the minimum amount of information necessary will be shared on a need to know basis. The Notice of Privacy Practices describes to patients how we may use or disclose their health information and patient rights regarding their protected health information.

Uses and Disclosures of Health Information

We may also use or disclose identifiable health information about you without your authorization for several other reasons. Subject to certain requirements, we may file our health information without your authorization for public health purposes, abuse or neglect reporting, auditing purposes, research studies, coroners, funeral arrangements and organ donations, workers compensation purposes, judicial/administrative proceedings, specialized governmental function and emergencies. We may also disclose identifiable health information to your relatives or friends involved in your treatment or payment for your treatment. We provide information when otherwise required by law, such as for law enforcement in specific circumstances. We may also contact you to leave you a message about appointment reminders or treatment alternatives. In any other situation, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures.

We may change our policies at any time. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area, in each examination room and on our Web site as applicable. You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person listed below.

Individual Rights

In most cases, you have the right to look at or obtain a copy of health information about you that we use to make decisions about your care. If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct the existing information or add missing information.

You have the right to request that your health information be communicated to you in a confidential manner such as sending mail to an address other than your home. If this notice was sent to you electronically, you may obtain a paper copy of the notice.

You may request in writing that we do not use or disclose your information for treatment, health provider communication or administrative purposes. We will consider your request but are not required to accept it.

Complaint

If you are concerned that we have violated your privacy rights or you disagree with a decision we made about access to your records, you may contact the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request. Under no circumstances will you be retaliated against for filing a complaint

Our Legal Duty

We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice.

If you have any questions or complaints regarding privacy, please contact our Privacy Officer at 314-780-9759.

CONFIDENTIALITY AGREEMENT FOR VISITORS IN CLINICAL AREAS

As a visitor at Balanced Body Rehab you are required to conduct yourself in strict conformance to all applicable laws and Balanced Body Rehab policies governing confidential information. Simply by being in the clinic, you may encounter confidential patient information. Care is often coordinated in
semi-public environments where there is the risk that patient information may be heard or viewed by individuals not directly involved in the patient’s care. Balanced Body Rehab has policies intended to limit the risks of such incidental disclosures of patient information. If you are exposed to private patient or business information, you are required to keep that information confidential. The private patient or business information you obtain in the clinic is to be kept confidential among Balanced Body Rehab staff and is forbidden to be discussed by all outside parties.

By signing this form you are authorizing us to use health information about you for treatment (such as sending your medical record information to a specialist physician as part of a referral), communication between your health providers (such as informing your personal trainer regarding precautions regarding your workout program) and for administrative purposes (such as comparing patients to improve treatment methods).

• I will access, use, and disclose confidential information only as permitted by Balanced Body Rehab hosts. This means that I will only access, use, and disclose confidential information that I have been given authorization to access, use, and disclose.
• I understand that any fraudulent application, violation of confidentiality or any violation of the above provisions will result in the termination of my privilege to observe and participate in rounds in clinical areas and I may be subject to legal liability as well.
• My signature below indicates that I have read, accepted, and agree to abide by all of the terms and conditions of this Agreement and agree to be bound by it.