*If you have a tertiary insurance please notify our office immediately*

Auto (NF) or Workers Compensation (WC)

APPLE CARE’s focus is your overall health and wellness. As we continue to strive to help you meet these standards, it is important to us that you understand the terms “Medically Necessary”, “Clinically Appropriate”, “Benefit Maximum Met” and how this relates to your treatment. “Medically Necessary” is defined as treatment or services that are specific to your diagnosis. When treatment is deemed medically necessary, your insurance company will reimburse Big Bear PT for services rendered according to physical therapy care that has a direct connection to document improved function based on our contractual agreement. “Clinically Appropriate” or “Benefit Maximum”: Insurance companies may deny care despite treatment that continues to manage, reduce or eliminate your pain. This may be “clinically appropriate” for your circumstances but may not be considered “medically necessary” by your insurance carrier. Benefit Maximum is defined as a sp ec ifi c number of phy sic al the rapy visits allowed by you r insurance policy during a specific time frame. Most treatments reach a point where no further improvement can be expected. This is called the point of maximum therapeutic benefit (MTB). MTB can be reached when complaints either fully resolve, or when pain and/or disability persist – even with ongoing treatment. “Denials/Appeals”: It is a patient’s responsibility to initiate an appeal with the insurance provider when services are denied. Big Bear PT will provide the necessary clinical information upon request. If your insurance company determines that services are no longer medically necessary, you will be billed $100.00 per visit for services that have been rendered. I understand it is my responsibility to confirm my coverage with my insurance carrier and that Big Bear PT may verify such coverage as a courtesy to me. Big Bear PT will not be held responsible or liable for inaccurate information or denials provided by your insurance carrier after services have been rendered. My signature below acknowledges that I have read and fully understand that: 1. Big Bear PT has discussed medical necessity limitations, clinically appropriate care, and specific number of office visits allowed per my insurance company. 2. I have been informed of my financial responsibility if my insurance company denies all or part of these services as not medically necessary. 3. I fully accept the financial responsibility to pay for denied services at the time my insurance carrier deems my treatment not medically necessary. 4. You are ultimately responsible for all payment obligations arising out of your treatment or care and guarantee payment for these services. You are responsible for deductibles, co-payments, co-insurance amounts or any other patient responsibility indicated by your insurance carrier.

(I) CONSENT TO RELEASE INFORMATION TO FAMILY OR FRIENDS Ordinarily, discussion of medical records or billing information would not be disclosed to anyone but yourself over the phone. However, with your consent, our staff will speak with your significant other, close family member or other designated individual. Please understand that you are waiving your right to confidentiality if this consent is given.

I am hereby giving my consent to Big Bear PT office staff to discuss my medical condition or billing concerns with the person/ persons I have designated below.

(II) CONSENT TO RELEASE INFORMATION TO A TELEPHONE ANSWERING MACHINE In an effort to protect your confidentiality, medical history and appointment reminder specifics (including date & time) will not be left on your answering machine, email and/or received in a text message; however, if you prefer us to do this, we can with your consent. Please understand that you are waiving your right of confidentiality if you give your permission.

I am hereby giving my consent for the Big Bear PT office staff to leave medical history or appointment reminders (including date & time) on my telephone answering machine, email and/or text message.

(III) PATIENT AUTHORIZATION TO TREAT AND SUBMIT MEDICAL CLAIMS I authorize payment to Big Bear PT for all physical therapy services rendered. I also understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered. I consent to be assessed by and to receive treatment from Big Bear PT consistent with a plan of care. I confirm that I have been informed and have participated in planning the care and procedure(s) to be carried out by Big Bear PT and sign this consent willingly and voluntarily. I consent to the release of information and/ or disclosure to Big Bear PT of all or any part of my medical record to other health care providers involved in my care or third-party payers as is necessary for processing claims. I am aware my child is receiving Physical/Occupational Therapy at Big Bear PT I am unable to attend his/her office visits. Please accept this form as my consent to treat my child.

I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENTS AND DISCLOSURES.

Big Bear PT NO SHOW/CANCELLATION POLICY As a courtesy to other patients, as well as the Big Bear PT staff, we require notification to cancel and/or reschedule appointments at least 24 hours prior to your scheduled appointment. Please make sure to reschedule your appointment if you are canceling. Missing or not showing to your scheduled appointment without proper advanced notification mentioned above, a fee of $35 will be collected upon your next visit. Should there be any misunderstandings or miscommunications regarding your scheduled appointment, please speak to one of us. REFERRALS PLEASE CHECK IF YOUR INSURANCE CARRIER REQUIRES A REFERRAL FROM YOUR PRIMARY CARE PHYSICIAN. REFERRALS ARE PATIENT RESPONSIBILITY AND MUST BE COMPLETED AND TURNED IN TO Big Bear PT ON TIME TO AVOID ANY INSURANCE DENIALS. VERIFICATION OF BENEFITS Big Bear PT verifies patient benefits with your insurance carrier as a courtesy to the patient. Benefits quoted are not a guarantee of payment. Patient is ultimately responsible for any denied services rendered at Big Bear PT WE THANK YOU IN ADVANCE FOR YOUR COOPERATION. PATIENT BILL OF RIGHTS Big Bear PT strives to ensure that each patient is provided the highest quality of care in accordance with high professional standards that are continually maintained and reviewed. We understand that patients have entrusted their care to us and we treat all patients with dignity, respect, and only provide appropriate services as needed. By requiring informed consent for treatment, we assure that each patient and/or his/her representative is involved in aspects of a treatment plan. Patients and their representatives are afforded consideration of their privacy concerning their own medical care program. Case discussion, consultation, examination and treatment are considered confidential and should be conducted discretely. The patient has the right to full information in layman’s terms concerning diagnosis, treatment and prognosis, including information about alternative treatments and possible complications. We will endeavor to involve patients in their treatment program by incorporating their feeling, interest, attitudes and goals in the treatment planning and implementation process. A patient has the right to physical therapy services without discrimination based upon race, color, religion, sex, sexual preference or national origin. I HAVE READ AND FULLY UNDERSTAND THE ABOVE PATIENT BILL OF RIGHTS.

Important Note: This Form should not be construed as offering or providing legal advice in any form. This Form is not intended to replace the reader’s need to speak with their own legal counsel regarding the issues presented. All readers should seek independent legal advice prior to instituting any re-entry policies and/or practices.