TO OUR VALUED PATIENTS:

We are committed to providing you with the best possible care.  If you have medical insurance, we are eager to help you receive your maximum allowable benefits.  In order to achieve these goals, we need your assistance, and your understanding of our payment policy.  We strongly encourage you recommend you to confirm your insurance responsibility with your medical Insurance Company. Should the information they give you regarding your coverage differ in any way please bring this to our attention immediately.

If a Deductible or Co-Insurance applies to your policy, we will send a statement for the patient responsibility after your claims have processed. You can prepay a predetermined set amount to avoid a large bill.   In the event of an over payment, after all the dates of service have been processed by your Insurance, a refund will be issued accordingly.  We will ask you to fill out the refund request form prior to payment.

Please read carefully:

1. PAYMENTS– Copayments and payment for services are due at the beginning of EACH If a Deductible or Co-Insurance applies to your policy, the quoted cost per visit is only an estimation. When additional patient responsibility is due after your claims have processed, you will receive a statement. In the event of an over payment, after all the dates of service have been processed by your Insurance, a refund will be issued accordingly.
2. IN NETWORK/OUT OF NETWORK-Your insurance is a contract between you, your employer and your insurance co. We are a participating provider for most insurance companies.  If we are in network, we will charge you no more than our contractual rate with your insurance company if applicable.  If we are out of network with your insurance company and your claims are submitted to your insurance company, you will be responsible for all reasonable and customary charges as indicated on the explanation of benefits received from your insurance company.  For more clarification on this, please speak with our Billing Staff.
3. BENEFIT LIMITS– Some insurance plans have a financial or visit limit for physical therapy services. It is ultimately your responsibility to know your benefit limits.  We have procedures in place to help you stay beneath any limits, but again it is ultimately your responsibility to keep track of your limits as if you exceed your limit, you will be responsible for charges not paid by your insurance company due to the exhaustion of your benefits.   
4. WORKERS COMPENSATION-If your injury is work related, and a Workers Compensation claim has been initiated, you must provide our office with your claim number, adjuster’s name and phone number before your initial visit. Please be advised that if your account is not paid by your comp. carrier, you will be responsible for all charges within 30 days of notification.
5. LIABILITY CASES-For liability cases, where another party is responsible, you need to provide us with all the billing information. If you have an attorney, please provide this information on the registration form. We must You will be responsible for the account in full.
   
   

We strive to provide our patients with the utmost professionalism and excellence of service. Our commitment to your well-being and gain of your physical abilities is something everyone in our clinic takes seriously.

Because we care so much about you, we realize it would be a disservice to you if we did not emphasize the importance of your commitment to the care you need to receive.

Your adherence to the recommended number of treatments is a vital component of your progress with our services; therefore, we have certain rules that need to be followed in order to ensure the most optimum results.

          We expect that you keep all scheduled appointments.

          We will give you a printed copy of your visits so that you do not forget.

          With the exception of serious emergencies, it is expected that you will attend. If you need to re-schedule, we require 24 hours notice.

          All missed or cancelled appointments MUST be made up the same week in order to comply with your physician’s orders.

          In the instance of non-sufficient notice of a cancellation or a no-show to a scheduled appointment, we reserve the right to charge you a $50 missed appointment fee.

          In the event of a 2nd no-show/insufficient notice cancellation, we will need to keep your credit card information on file to collect payment(s). ***Cards kept on file will NEVER be charged without prior notification***

Please be advised that cancelling more than 3 visits may also result in a compliance report being sent to your physician and possible discharge

We also reserve the right to discontinue care and will inform your physician of the fact that you service has been discontinued due to non-compliance with the physical therapy order.

 We appreciate you greatly as our patient and strive to accomplish wonderful results and success for you. The only way for us to accomplish these results is to ensure that you are here for all recommended visits.

I have read this policy and understand that I will be charged a $50 fee if I do not give proper notice in any instance where I miss a scheduled appointment.

Purpose: This notice describes how medical information about you may be used and disclosed. This notice also describes how you can get access to this information. Please review it carefully.

Virtuous Wellness Center, would like you to know that we have specific policies in place to safeguard your protected health information (PHI). These policies are in accordance with HIPPA, the federal government’s mandated privacy and security program.

Your PHI is gathered and used for the following reasons:

1. To provide treatment (ex: sending medical information to the referring doctor)
2. To secure payment (ex: sending chart notes to the payer source)
3. To complete healthcare operations (ex: sending charts to our physical therapy network for quality assurance review; courtesy phone calls to remind you of your appointment or reschedule missed appointments; post discharge patient satisfaction surveys)

If your PHI is needed for other uses or disclosures, your written authorization will be obtained prior to releasing any information. You may revoke your written authorization at any time.

You do have the right to restrict some of the uses of your PHI as outlined above. However, this facility may elect to not treat you if your restrictions prevent us from engaging in normal business practices such as billing and collecting or obtaining medical clearance from your physician to treat. You have the right to access your records, copy and amend your records and request confidential communications. You may obtain a copy of disclosures that would have required authorization.

You have the right to complain about our privacy practices to the department of Health and Human Services.

Finally, it is our intent to follow the law as it relates to maintaining the confidentiality of your PHI, provide you with this notice and to follow our own policy. We reserve the right to change our privacy policies and the terms of this notice at anytime as well as to make new practices and notice effective for all PHI maintained. Please know that any questions or complaints regarding our privacy practices will not result in retaliation from our facility. If you have any questions, please contact the privacy officer.

Effective 11/01/2019

Acknowledgment

I have received a NOTICE OF PRIVACY PRACTICES from Virtuous Wellness Center. I have read and understand how my PRIVATE HEALTHCARE INFORMATION (PHI) is used and/or disclosed for treatment, payment, or healthcare operations. I understand that I may request in writing any restrictions of the use of my PHI. I also understand that if my restrictions limit Virtuous Wellness Center from engaging in normal business practices that Virtuous Wellness Center may elect to deny treatment. Finally, I have been informed by Virtuous Wellness Center that their privacy officer  can be reached at 410- 353-9911.