Branch and Body Wellness, LLC 

CONDITIONS & CONSENT FOR PHYSICAL THERAPY

COOPERATION WITH TREATMENT:

I understand and agree to cooperate with and perform the home physical therapy program intended for me.

NO WARRANTY:

I understand that the physical therapist cannot make any promises or guarantees regarding a cure for or improvement in my condition. I understand that my physical therapist will share with me opinions and available statistics and studies regarding results of physical therapy treatment for my condition and will discuss treatment options with me before I consent to treatment.

INFORMED CONSENT FOR TREATMENT:

The term “informed consent” means that the potential risks, benefits and alternatives of physical therapy treatment have been explained to you. The therapist provides a wide range of services and I understand that I will receive information at the initial visit concerning the treatment and options available for my condition.

Potential risks: You may experience an increase in your current level of pain or discomfort, or an aggravation of your existing injury or condition. This discomfort is usually temporary; if it does not subside in 24-48 hours, I agree to contact my physical therapist.

Potential benefits: May include an improvement in your symptoms and an increase in your ability to perform daily activities. You may experience increased strength, awareness, flexibility and endurance in your movements. You may experience decreased pain and discomfort. You will have greater knowledge about managing your condition and the resources available to you.

Alternatives: Physical therapy treatment options will be explained and recommended for your conditions. If you subsequently decide not to pursue further care with Branch and Body Wellness Physical Therapy, we will encourage you to follow up with another desired provider (physician, therapist, trainer, coach, etc).

FINANCIAL AND INSURANCE RESPONSIBILITIES:

I agree to pay for my treatments at time of service, by cash or credit card unless other mutually agreed upon arrangements have been made.I acknowledge that I have chosen, of my own free will, to obtain the services provided by Branch and Body Wellness Physical Therapy and have agreed to pay out of pocket for my services without any expectation that my health plan will reimburse me.  If I am a Medicare beneficiary, I attest that I have chosen not to use my Medicare benefits for the services I am purchasing and am restricting Branch and Body Wellness Physical Therapy and my therapist from submitting any claims to Medicare pursuant to my right to privacy under HIPAA.  Please see the Branch and Body Wellness Physical Therapy Payment Terms for more information.

I have read the information, and I consent to physical therapy evaluation and treatment. I have asked any questions and they have been answered to my satisfaction. I understand the risks, benefits and alternatives to treatment. I hereby voluntarily consent to physical therapy treatment. I understand that I may choose to discontinue treatment at any time.

Branch and Body Wellness, LLC PAYMENT TERMS

▪  Cash-Based Services:You agree to be financially responsible for all charges regardless of any applicable insurance or benefit payments, third-party interest, or the resolution of any legal action or lawsuits in which you may be involved. You acknowledge that you have chosen, of your own free will, to obtain the services provided by Branch and Body Wellness, LLC and have agreed to pay out of pocket for such services without any expectation that your health plan will reimburse you or pay Branch and Body Wellness, LLC.  If you are a Medicare beneficiary, you attest that you have chosen not to use your Medicare benefits for the services you are purchasing and are restricting your therapist from submitting any claims to Medicare pursuant to your right to privacy under HIPAA.

▪  Payment: Payment is required at time of service unless you have made other payment arrangements with us. We accept cash or credit card at the time of service. 

▪  Rates: The rates are as follows: $185 per hour. Rates are based on time spent with you and the treatments performed during your appointment. 

▪  No Insurance Patients: Branch and Body Wellness, LLCis not a preferred provider for insurance companies.  Instead, it is a cash based practice. By not having a preferred provider/contracted status with the insurance companies, the therapist does not have to limit the time or quality of treatment provided secondary to insurance company restrictions or elevate clinic rates to pay for billing services.

▪  Use of Health Savings Accounts (HSA), Health Reimbursement Arrangement (HRA) or Flexible Spending Account (FSA).  We accept payment from these accounts for medically necessary services.  If you are purchasing wellness or fitness services, consult the IRS guidelines and your plan rules to determine whether your services qualify for payment from an HSA, HRA or FSA account.  

▪  Out-of-Network Policy.  (Commercial Health Plans - Does not apply to Medicare) We are out-of-network with all health plans.  If you have out-of-network benefits, we will provide you with a copy of your bill that you can, at your discretion, submit to your health plan for reimbursement for the services your health plan covers. You understand that even if you have out of network benefits, you may be required to pay a higher copay or coinsurance for out of network services and you may have separate out of network deductibles and out of pocket maximums.  You are responsible for contacting your insurance company to determine what your benefits are and obtain any necessary physician referrals and/or pre-authorizations for services. We are not responsible if your health plan denies, in whole or in part, your claims for our services.  

▪  No Medicare Patients: We do NOT accept Medicare and patients cannot be reimbursed by Medicare for visits. 

▪  Medicare Policy (for Medicare Part B and Medicare Advantage Plans).  If you are a Medicare beneficiary, you understand that providers operating under Branch and Body Wellness Physical Therapyare not enrolled as Medicare providers.  Medicare has onerous technical and administrative requirements that must be met for services to be considered medically necessary covered benefits.  We believe those requirements take unnecessary time away from the services we provide and some of the services we offer are not covered by Medicare.  Since we are not enrolled providers, we cannot submit claims to Medicare and Medicare will not pay for our services even though the same services might be paid by Medicare if you obtain them from a Medicare enrolled provider. If you want Medicare to pay for services that might be considered covered benefits, you should seek those services from a Medicare enrolled provider.  If you decide at any point after you start services with us that you want Medicare to pay for the services it covers, we will be happy to recommend a Medicare enrolled provider and terminate your services with us.  As a condition of us providing services to you, you are choosing, of your own free will, not to use your Medicare benefits and agreeing to pay privately at the time of service for all services you elect to receive from us with no expectation that Medicare will reimburse you.  You understand that we will not submit claims to Medicare on your behalf and agree that you, your caregivers, family members, authorized representatives or power of attorney will not, under any circumstance, submit our claims, invoices, receipts or statements to Medicare for reimbursement.

o   Medicare supplemental plans.  Medicare supplemental plans will not reimburse you for our services because we are not enrolled providers with Medicare.  Therefore, you should not choose to see us if you are expecting to be reimbursed by your supplemental plan.

o   Medicare as primary payer, Commercial Plan as secondary payer.  If you have a commercial health plan as a

secondary payer, you will not likely be able to use it because the commercial plan will probably require you to submit claims to Medicare first or obtain a Medicare denial. We cannot submit claims to Medicare just to get a denial.   o Commercial Plan as primary payer, Medicare as a Secondary Payer.  If you have a commercial insurance plan, we will provide you with a copy of your bill that you can, at your discretion, submit to your commercial health plan for reimbursement for the services your health plan covers.  However, since we are not Medicare enrolled providers, Medicare will not pay your copays, co-insurance or deductibles as a secondary payer. You agree that you, your caregivers, family members, authorized representatives or power of attorney will not, under any circumstance, submit our claims, invoices, receipts or statements to Medicare for reimbursement of copays, coinsurance or deductibles that your commercial health plan does not pay.

▪  Cancellation Policy.  We require a 24-hour notice to cancel a scheduled appointment. If you cancel with less notice, you will be required to pay the full cost of the visit.  We reserve the right to waive this policy at our sole discretion.

▪  Privacy Rights.  You have a right to privacy under the Health Insurance Portability and Accountability Act (HIPAA) that includes restricting disclosure of your records and claims to your health plan, including Medicare, if you pay privately for your services at the time of service.  If you pay for your services at the time of service, we assume you are exercising this right to privacy we will not disclose your medical records to any third party, including your health insurance carrier or Medicare. If you want your records disclosed to any third party in the future, you will need to sign our Authorization to Release Protected Health Information form before we will do so. 

▪  Appeals Policy.  You understand that you are responsible for filing all appeals of adverse benefit determinations. If you need assistance filing an appeal, contact the consumer assistance agency on your denial letter.