Adult Occupational Therapy - Clinic Policies/General Medical History/HIPAA Notice of Privacy Practices
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Clinic Policies
Please read the following policies. Print copy of this document for your records.
For each of the sections below, please type your initials in the field below the text to acknowledge the content.
Scheduling/Participation *
In order for you to reach your established treatment goals, it is imperative that scheduled therapy sessions be consistently attended. We are aware that unanticipated emergencies (e.g. illness, vacations) take place. We require that you maintain a 75% attendance rate at your regularly scheduled time slot.  If appointments are not attended on a consistent basis, you may be moved to a different treatment time slot.
Late Arrival *
We attempt to start all therapy sessions on time. Therefore, we ask that you be punctual for your session. If you arrive late for your appointment that time will be deducted from the overall scheduled time and will subsequently reduce the amount of direct treatment time that you will receive during that therapy session. If untimely attendance occurs on a consistent basis, you may be moved to a different treatment time slot.
Late Cancellations *
We request 24 hours’ notice for a canceled appointment in order for our therapists to have the opportunity to adjust their schedule accordingly. An appointment that is not canceled at least 24 hours prior to the scheduled appointment time is considered a Less Than 24 Hour Cancellation and you will be charged full fee for the scheduled therapy session. Certainly, we understand that there are exceptions to this policy, such as family emergencies, which are not possible to control. Please note that it is your responsibility to contact our office as soon as possible to eliminate any extra fees. You may also contact our office at the number above and leave a message after hours.
Notice to Discontinue Treatment *
If you choose to discontinue therapy services, you will need to provide 30 days’ notice prior to your last session. NHWS is willing to accommodate two week prior notice for unique circumstances which will be determined on an individual basis. If you choose to discontinue services before clinically indicated, we require notice in order to allow appropriate termination of service including but not limited to: allowing time for any retesting that may be necessary to summarize your program and progress, provide a home program specific to your needs, and adequate time to compile documentation for referral and reimbursement providers. Cancellation of therapy services must be received in writing (verbal cancelations will not be accepted). If the proper notice is not provided, you will be held financially accountable for up to four weeks of therapy services at the full rate if not covered by your insurance carrier.
Patient Care *
New Horizons Wellness Services shall provide occupational and speech therapy services and materials in compliance with the orders of the patient's attending physician. Administration of treatments will be delivered as ordered by said physician.  (1) Consent to treatment: You and/or your representative acknowledge that you are under the medical treatment and care of said attending physician, and that NHWS is rendering services to you under the general and specific instructions of said physician. You and/or your representative recognizes that said physician furnishing services to you is an independent agent and is not an employee or contractor of NHWS. (2) Restrictions and liabilities: NHWS shall incur no liability for injuries of any kind suffered by you while under care; therefore, should you discontinue treatment before the attending physician has so ordered, you and/or your representative agrees to assume all responsibility for all results which follow. (3) NHWS is not liable for injury caused by visitors attempting to assist or treat you in any way.
Payments *
Payment is due at the time services are rendered. The individual who brings the patient to therapy is responsible for payment of the therapy session. Please make all checks payable to New Horizons Wellness Services, LLC. Please note that there is a $40.00 charge for all returned checks. The credit card receipt provided at the time of services is your receipt. Statements are provided upon request only.
Insurance Billing
You are required to pay your annual out-of-network or in-network deductible at the beginning of your plan’s calendar year. After your out-of-network or in-network deductible has been satisfied, you are responsible for the co-pay or co-insurance amount set by your insurance carrier. Any non-covered services are your financial responsibility.

Co-payments, co-insurance, non-covered services and/or deductibles are your responsibility and are due at the time services are rendered. In the event that payment for a performed service is denied by your insurance carrier, it is your responsibility to pursue action with them, as the policy is a legal contract between you and your insurance company.
We do not bill secondary insurance *
Visit Limits *
Visit limits are set by your insurance carrier. If your insurance policy has visit caps or limited visits, it is your responsibility to track these visits as they occur. If you have participated in any therapy services with another provider during the insurance year, then you will need to include those visits. This is especially important if additional services such as occupational therapy, physical therapy, etc. are also being received.
Patient Release for Interns and Volunteers
NHWS is a teaching clinic so on occasion student interns from various colleges may accompany your therapist, observe treatments, and have sight of their notes. A background check through each respective institution is conducted for each student intern. NHWS periodically allows volunteers to assist in the clinic. They may be in the treatment area with you under the supervision of your therapist. Each volunteer has HIPAA privacy instructions. Volunteers are in place to learn, to assist the therapist and to work for the benefit of patient care. Volunteers are not employees of NHWS and cannot assist you with billing, scheduling, medical or insurance information.
Signature *
By signing, I understand that my treatment, testing, evaluations, daily notes and/or invoices may be seen by student interns in training to become Occupational Therapists, Speech Pathologists, and by volunteers. I understand that the student interns and/or volunteers may be involved in my treatment.
Release of Information *
I understand that it is necessary for New Horizons Wellness Services receive either proof of guardianship or permission from the patient to share any details regarding evaluation or treatment (orally or through written documentation) with parents or other family members. This is in reference to legal policy regarding privacy laws/confidentiality, in addition to the privacy polices of NHWS. If legal guardianship is not provided, the patient must fill out and sign an Authorization To Use and Disclose Protected Health Information form prior to any discussion of services with those other that the patient (verbal consent will not be acceptable).
Photo/Video/Website/Print Consent *
I authorize NHWS to use my photo(s) in our brochures, printed materials, and in the clinic, my photo(s) and/or video(s) on our website for the use of public relations, promoting various NHWS occupational or speech therapy programs.
I understand that I will be notified before the use of the photo(s) and/or video(s). *
Contacting Your Therapist *
Please note that telephone calls are answered between 9:00 am - Noon and 1:00 - 5:00 pm, Monday through Friday. Messages may be left on our voice mail system. We will make every effort to return your call on the same day you make it, or at least within 24 hours, with the exception of weekends and holidays. Electronic communication, (email), presents a potential risk to patient confidentiality.  While patients may find this a convenient way to communicate they must be aware of the risks. We will respond should you choose to email us regarding non-clinical issues such as appointment scheduling. Please note we will not engage in "therapy" nor respond to casual "chats" via email. Information exchanged by fax/email will become a part of the clinical record.
Therapy Dog Consent *
I authorize NHWS to use a therapy dog in therapy session as part of my treatment. Mention Yes/No and Initials
Your signature below validates your initials on each of the clinic policies described above.
Electronic Signature Agreement:
 By selecting the "Submit" button at the end of this form, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "Submit" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and New Horizons Wellness Services, LLC. You are also confirming that you are the responsible party authorized to enter into this Agreement.
Patient’s Name *
Signature *
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