New Client Intake Forms
Please fill out the form below.
Financial Agreement
Holy City Needling and Therapy LLC is a Cash-Based Practice and I, your licensed therapist, am considered an out of network provider. This means that this practice has not established an agreement with insurance companies for reimbursement. In a Cashed-Based treatment setting, the PT and the patient enter an agreement in which the patient understands that they are fully responsible for the cost of services at the time of treatment. Although this is a cash-based practice, Holy City Needling and Therapy LLC can accept payment via check or credit card as well. This model allows the therapist to focus on providing the most appropriate treatment while keeping administrative costs low.
Documentation for all treatment will still be performed like any other physical therapy practice. Typically, the bills a patient would receive from a physical therapy office will vary from session to session based on the exact treatment provided during that session. At Holy City Needling and Therapy LLC, we can focus on your exact needs without the stress of what type of bill a patient may receive for a specific session.
Medicare Patients:
If you are a Medicare beneficiary (including a Medicare supplemental insurance plan, Medicare Advantage Plan, or Medicare Replacement Plan), you understand that I, your licensed therapist, am not enrolled as a Medicare provider. Medicare has arduous technical and administrative requirements that must be met for services to be considered medically necessary covered benefits. I believe those requirements take unnecessary time away from the services I provide. In addition, many of the fitness/wellness services I offer are not covered by Medicare. Since I am not an enrolled provider, I cannot submit claims to Medicare and Medicare will not pay for my services even though the same services might be paid by Medicare if you obtained them from a Medicare enrolled provider. Therefore, by choosing my services, you are exercising your right to privacy and electing, of your own free will, not to use your Medicare benefits. As such, you are agreeing to pay for all services you elect to receive with no expectation that Medicare will reimburse you. You understand that I will not submit claims to Medicare on your behalf or provide you with a statement or billing codes that you can submit to Medicare yourself. 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, that you want Medicare to pay for the services it covers, I will be happy to recommend a Medicare enrolled provider and terminate your services with me. You agree that you, your caregivers, family members, authorized representatives or power of attorney will not, under any circumstance, submit my claims, invoices, receipts or statements to Medicare for reimbursement or to obtain a denial for a Medicare supplemental insurance plan.
Note: For those with Medicare as a Secondary Payer, if you choose, I can provide you with a copy of your bill that you may submit to your commercial plan for reimbursement; however, since I am not a Medicare enrolled provider, Medicare will not pay your co-pays, co-insurance, or deductibles as a secondary payer. By signing this, you agree to carry out whatever procedures are necessary to prevent your commercial insurer from forwarding my bills to Medicare.
HIPPA
This Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. I am are not required to agree with this restriction, but if I do, I shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to my use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
NOTE: This is not a medical records release for physical therapy records, you must sign a separate Medical Release form to obtain records from our office.
By signing this form, I understand that:
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Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
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The practice reserves the right to change the privacy policy as allowed by law.
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The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
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The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
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The practice may condition receipt of treatment upon execution of this consent.
Physical Therapist Signature
Informed Consent for Physical Therapy Services
The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis, and intervention by use of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum potential within their capabilities and to accelerate convalescence and reduce the length of functional recovery. All procedures will be thoroughly explained to you before you are asked to perform them.
Response to physical therapy intervention varies from person to person; hence, it is not possible to accurately predict your response to a specific modality, procedure, or exercise protocol. Karlye Cappelmann, PT, DPT, does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for. Furthermore, there is a possibility that the physical therapy treatment may result in aggravation of existing symptoms and may cause pain or injury. It is very important to communicate with your treating physical therapist throughout your treatment.
It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns. It is your right to ask your physical therapist about the treatment they have planned based on your individual history, physical therapy diagnosis, symptoms, and examination results. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment.
I have read this consent form and understand the risks involved in physical therapy and agree to fully cooperate, participate in all physical therapy procedures, and comply with the established plan of care. I authorize the release of my medical information to appropriate third parties.
Dry Needling Informed Consent
Please review the following information PRIOR to consenting to application of dry needling techniques which is recommended by your physical therapist as a part of the physical therapy plan of care. Dry Needling is a technique that utilizes thin, solid filament needles to treat myofascial trigger points, muscle spasms, or dysfunctional tissue.
Like any medical procedure, there are possible complications. While these complications are uncommon, they do sometimes occur and must be considered prior to giving consent to the procedure.
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You may experience an increase in pain for one to two days followed by an expected improvement in your overall symptoms.
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You may experience a general feeling of fatigue following treatment as your body requires energy to assist in healing the tissue dysfunction.
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A needle may be placed inadvertently into the lung tissue creating a small hole in the lung. There is minimal risk involved with a cautious and experienced physical therapist performing dry needling.
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You may experience a small bruise or localized bleeding in the region of the inserted needle.
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You may also experience any of the following during treatment: A feeling of relaxation, an increase in energy level, dizziness, nausea, sweating, or irritation at the site of needle insertion.
I have read this form and I understand the risks involved with dry needling therapy. I have had the opportunity to ask questions and express any concerns, of which have been answered to my satisfaction. I also agree to advise my physical therapist of any and all changes in my physical condition whether or not I believe these changes will affect my physical therapy plan of care.
I consent to dry needling treatment provided by my physical therapist.