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Request for Contact

Patient Agreement

Insurance

PLEASE PROVIDE YOUR CARD TO THE FRONT DESK

Authorization & Consent

  • I understand that I am responsible for all of the charges regardless of the insurance or the third party liability. 
  • I authorize contact by the use of my phone number for discussing treatment, confirming appointments and resolution of the balance of my account.
  • I authorize Eschman PT, LLC to release any of my medical information necessary to process my claim to my insurance company or to any other concerned third party. 
  • I understand that I will bear the cost for all associated collections and/or attorney or legal fees if my account is place with a third party agency and/or attorney for collections or legal action.
  • I authorize my insurance company or any other 3rd party to make copayment directly to Eschman PT, LLC.
  • There may be a $35.00 charge billed to the patient for repeated cancellations or no shows without a 24 hour notice.
Financial Policy and Consent to Treat

By executing this agreement, you are agreeing to pay for all services that are received.


Monthly statements:  If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to the account, the fiancé/rebilling charge, if any, and any payments or credits applied to your account during the month.


Payment options if you have insurance.

1. If you have a deductible to meet, you choose to pay by ___cash, ___check or ___credit card at the time services are rendered. We will send your claim to your insurance carrier and will bill you for any additional patient responsibility, if any, which is determined by your carrier. 

2. You choose to pay your co-payment, determined by your insurance carrier, by ___ cash, ___check, or ___credit card at the time services are rendered. If there is a balance on your account at the end of the month we will bill you accordingly.

Payments:  Unless other arrangements are approved, the balance of your statement is due and payable when the statement is issued and is past due if not paid by the end of the month. If extenuating circumstances should arise, you can discuss a payment plan without billing department at 330-372-5800


Consent for Care and treat

that is considered necessary and proper in diagnosing or treating his/her physical and mental condition.

Contracted Insurance:  If we are contracted with your insurance company, we must follow our contract and their requirements. It is the insurance company that makes the final determination of your coverage eligibility. Our billing will verify your benefits with your insurance company and determine if a preauthorization is required.


Non-contracted Insurance:  Insurance is a contract between you and your insurance company. We are NOT a party to this contract, in most cases. We will bill your primary insurance as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your coverage eligibility. You agree to pay any portion of the charges not covered by the insurance.


Past Due Accounts:  If your account becomes past due, we will take necessary steps to collect this debt. We reserve the right to refer your account to an attorney or collection agency. You agree to pay all attorney fees and collection costs incurred in enforcing the terms of this agreement.


Missed Appointments:  If you find that you cannot keep your scheduled appointment, we ask that you cancel at least 24 hours in advance. Failure to cancel with less than 24 hours notice or “NO shows” will result in a cancellation fee of $35.00 per appointment. This charge must be paid in full before receiving any further treatment.


Workers Compensation:  We require written approval/authorization by your worker’s compensation carrier prior to your initial visit. If your claim is denied, you will be responsible for payments in full.


Motor Vehicle Accidents:  In the event your injury is due to a motor vehicle accident we will be billing your health insurance company. You will be held responsible for any copayments, deductibles, and co insurance. Ohio state law allows us to do that.


Effective date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.

HIPAA Notice of Privacy Practices

At Eschman Physical Therapy, LLC we strive to protect your health information and your rights as a patient. Here are our common practices in dealing with patient health information.


Uses and disclosure of health information:   

At Eschman Physical Therapy, LLC we will use and disclose your health information in order to treat you or to assist other health care providers in treating you. We may also use and disclose health information in order to obtain payment for our services or to allow insurance companies to process insurance claims for services rendered to you by us or other health care providers. Finally, we may disclose your health information for certain limited operational activities such as quality assessment, licensing, accreditation and training of students.


Uses and disclosure based on your authorization:

In the following circumstances, we may disclose your health information without your written authorization.


Uses and disclosures not requiring your authorization:

In the following circumstances, we may disclose your health information without your written authorization:

  • For the purpose of health and safety.
  • To Government agencies for purposes of their audits, investigations, and oversight activities.
  • To Government authorities to prevent child abuse and domestic violence.
  • To law enforcement authorities to protect public safety or to assist in apprehending criminal offenders.
  • When required by courts orders, search warrants, subpoenas, and as otherwise required by law.

Patient Rights:

  • As our patient, you have the following rights: 
  • To have access to and/or copies of your health information.
  • To receive an account or certain disclosures we have made if your health information.
  • To request restrictions as to how your health information is used or disclosed.
  • To request that we communicate with you in confidence.
  • To request that we amend your health information.
  • To receive notice of our privacy practices. 

Please let us know if you have any questions, concerns, or complaints regarding our privacy practices.


I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so choose) and understand the notice.

How did you hear about Eschman Physical Therapy, LLC

Release of information

I hereby authorize the release and exchange of any information regarding the following:

  • Evaluation/Treatment reports
  • Diagnosis
  • Billing information


Information to be disclosed date range: 


for the purpose of sending Primary Care Physician. 

Eschman Physical Therapy, LLC

2581 North Rd NE Suite A

Warren, OH 44483

(330) 372-5800 Phone

(330) 372-5841 Fax



AND

This release will expire 180 days from date of signature.

Patient may revoke their consent to release information in writing.

Telehealth Patient Consent / Refusal Form

Purpose:  The purpose of this form is to obtain your consent to participate in a Telehealth Consultation/Treatment in connection with the following procedure(s) and/or service(s)

  1. Nature of Telehealth Consult: During the telehealth consultation: 
    1. Details of your medical history, examinations, x-rays, and tests will be discussed with other health care professionals through the use of interactive video, audio, and telecommunication technology.
    2. A digital physical examination may take place. 
    3. A non-medical technician may be present in the telehealth studio to aid in the video transmission.
    4. Video, audio and or/photo recording may be taken of you during the procedure(s) or service(s) for treatment purposes only.
  2. Medical information & Records:  All existing laws regarding your success to medical information and copies of your medical records apply to this telehealth consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient identifiable images or information for this telehealth interaction to any other parties or entities shall not occur without your consent. 
  3. Confidentiality: Reasonable and appropriate efforts have been made to eliminate any confidential risk associated with telehealth consultation, and all existing confidentiality protections under state and federal law apply to information disclosed during this telehealth consultation.
  4. Rights: You may withhold or withdraw your consent to the telehealth consultation at any time without affecting your right to future care or treatment.
  5. Risks, Consequences & Benefits: You have been advised to all the potential risks, consequences and benefits of telehealth. Your health care provider has discussed with you the information provided above.
  6. I agree to participate in telehealth care with Eschman Physical Therapy, LLC for the procedure(s) and/or service(s) above.
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