Pelvic Health (PH) agrees to bill my insurer for services. Following payment from my insurance company, I am responsible for any amounts due including deductibles, coinsurance, or any other charges not covered by my insurance.
I understand that co-pays are due at the time of each therapy visit. Failure to pay at the time of my visit may result in an additional 5$ fee to be paid by me for each late co-pay.
I understand that the all cancellations are to be made 24 hours prior to my visit. Pelvic Health reserves the right to charge a $40 fee for missed or cancelled appointments.
It is imperative that I provide Pelvic Health with all insurance information (primary, secondary, etc) as well as any changes in my insurance prior to each visit. Failure to do so will result in my being responsible for any and all charges that Pelvic Health is unable to collect for as a result.
Interest will accrue at 1.5% per month on any balance over 30 days old that is deemed my responsibility. If my account is sent to collections and/or small claims court, I will be responsible for any collection expenses and/or court costs.
I authorize release of any medical information necessary to process any insurance claims and I authorize payment of medical benefits directly to Pelvic Health for myself and/or my dependents.
I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or related Medicare claim. I request that payment of authorized benefits be made on my behalf to Pelvic Health
I hereby consent to voluntarily engage in physical therapy treatment and services deemed necessary by my physical therapist and/or physician. I understand that physical therapy is not an exact science and I acknowledge that no guarantees have been given to me as far as my treatment.
Please indicate whether you have, or have had any of the following problems; include dates. This information will help us create a safe effective treatment plan. Certain types of therapy are not used depending on your medical status/history.
I hereby give my consent to Pelvic Health to send physical therapy notes, and to discuss information regarding myself or my child, to my primary and referring physicians, my authorized representative, my case manager and my insurance companies. I also understand that my health information may be used to carry out my care and treatment, to obtain payment, and for this organization's health care operations.
As a patient/client, you have the right to request that Pelvic Health restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement. We require that this request be put in writing.
A more complete description of uses and disclosures is in Pelvic Health's 'Notice of Health Information Packet' which is on page three of this document.
I further authorize Pelvic Health to obtain medical records, make phone contact, or obtain other information related only to my treatment plan. Fax transmissions may be used.
A more complete description of uses and disclosures is in Pelvic Health's 'Notice of Health Information Packet'. A copy of this form follows. Please read the copy of Pelvic Health's 'Notice of Health Information Practices'.
Each time you visit your physical therapist your visit is recorded. This record may contain your symptoms, diagnoses, test results, and a treatment plan and notes. This information becomes part of your medical record and helps healthcare professionals plan your care and treatment. As a consumer of healthcare, it is important for you to understand what is in your medical record, who may have access to your record, and how information about you may be used for healthcare related and non-healthcare related purposes.
Pelvic Health is committed to safeguarding the confidentiality, security and integrity of your medical record. Additionally, Pelvic Health has drafted this notice to be in compliance with federal standards for safeguarding the privacy of protected healthcare information and to help you understand your rights and our responsibilities with respect to your medical record.
We reserve the right to revise or change this Notice at any time. If there is any significant change in Pelvic Health's privacy policies, this Notice will be changed and the new Notice will be available upon your request.
It is important to understand that a medical record is an important historical document. While the information in the record belongs to you, the physical record is the property of Pelvic Health. In this regard, you have the following rights:
As a healthcare organization, we will do the following:
Confidentiality of Minors' Records:
The child's parent or guardian should determine access to the medical records of a minor child (under the age of 19). However, in rare circumstances a child may be emancipated or may state thats/he does not want her/his parents or guardians to have access to the records. A parent may be denied access to their child's medical records if Pelvic Health has been provided with a certified copy of a court order, indicating that the parent has no legal rights and responsibilities for the child.
We require that any request to inspect or copy records, for amendments to medical records, request for restrictions on contents or usage of your medical record, requests to revoke consent or authorizations, request for accounting of disclosures, and request for confidential communication with you, be made in writing.
Please contact us if you have any questions or concerns about the confidentiality and security of your medical records or about your rights and our responsibilities. If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services.
Please call or write:
The muscles of the pelvic floor are located inside the pelvis between the pubic bone (in front) and the tail bone or coccyx (in back). They function as support for the internal organs, help control elimination from the bladder and the bowel, and are involved in sexual response.
The physical therapist does a manual exam, both externally and internally, of the muscles, as well as muscle biofeedback (EMG biofeedback) to help determine if your muscles are weak, if they have low endurance, or if they have elevated activity at rest (“spasm”). Internal structures will be examined by the Physical Therapist by inserting 1-2 fingers into the rectum/vagina. You may be asked to perform a series of muscular contractions to evaluate the strength of the pelvic floor musculature.
Weak pelvic floor muscles may cause you to be incontinent of bladder or bowel. This may happen with coughing, sneezing, or other stressful events. Conversely, the muscles may have increased tension and may become painful if they are tightened for a long period of time. They may also spasm, causing a dull aching pain through the pelvis, buttocks or hips and occasionally down the leg. The pain may present itself as pressure, burning, or aching that is localized in the pelvic organs, genital region, and or bones of the pelvis or abdomen.
Information you possess about your health status or your symptoms such as pain or pressure may affect the ability of the therapist to accurately assess the pelvic floor. You are responsible for fully disclosing your medical history, as well as any symptoms that may occur during the assessment.
A physical therapy evaluation will help decide the best approach to eliminating and managing pain, as well as strengthening weak muscles. Home exercises are frequently used to help strengthen the pelvic floor muscles. You might be instructed in exercises to help relax these muscles. Posture and therapeutic exercises are frequently recommended. It takes some time for you to build your awareness of the pelvic floor muscles and learn to either relax, or strengthen them. Biofeedback is helpful in this area. We use a sensor that we sell to you ($40.00) and you bring to each session (these are not covered by insurance).
I hereby consent to voluntarily engage in a pelvic floor assessment to determine the potential need for pelvic floor treatment. My permission to perform this assessment is given voluntarily. I understand that I am free to stop the assessment at any point, if I so desire.