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Policies and Forms

Please click on the forms below to download and fill in the needed information.

$20.00 Class Fee plus tax
$100.00 per hour session plus tax
$130.00 Initial evaluation plus tax

Policies 2018

Cancellation Policy:

Patients who cancel with fewer than 24 business hours notice for any reason will be charged $100. For example, you must call by Friday at 3:00 pm to cancel a Monday 3:00 pm appointment. In return, I will offer you the same courtesy. If I cancel your appointment with fewer than 24 business hours notice, I will credit you $100.

The one exception to the 24 business hours rule is snow. In the case of snow, I will follow the lead of the local schools and government offices. For example, a two hour delay will exempt the 8:00am and 9:00am patients and school closures will exempt all patients from the cancellation policy for that day. Please note, I have never missed work because of snow and plan to be in the office if you want to keep your appointment on a snow day.

Payment Policy:

Payment is due at the time of service. Cash, checks and credit/debit cards are accepted. A 3.25% convenience fee will be added to all card transactions.

Medicare Benefit Policy:

Physical therapists cannot opt out of the Medicare program at this time. As a result, I cannot provide covered physical therapy services to Medicare patients. However, there are two exceptions to this rule:
        1.  I can provide services to Medicare patients that are otherwise not covered such as wellness,
             prevention, and fitness.
        2.  If a Medicare patient “refuses, of his/her own free will, to authorize the submission of a bill to
             Medicare” (section 40, chapter 15 of the Medicare Benefit Policy Manual), I can accept self
             payment for physical therapy services.
If you meet one of the two conditions above and want to come see me, I will be asking you to sign an agreement that states neither you nor I will send claims to any 3rd party payor (Medicare and all secondary insurances) and you will not allow anyone else to send claims on your behalf.

Your Privacy Rights:

Karen’s HIPAA Notice of Privacy Practices
As your physical therapist, I believe your right to privacy is a fundamental part of your treatment; as such, I want you to understand my privacy practices and procedures. Should you have any questions regarding these policies please ask.

Information I collect about you: I collect personal information about you as part of the registration process, during the course of your care, and from other health care entities you utilize such as hospitals, physicians/specialists, and imaging facilities. This personal information includes items such as your name, address, phone number, email address, date of birth, employer, health history, and any other information you provide.

How your information is used: The personal and health information gathered may be used and disclosed with your general consent for the following purposes: treatment, securing payment, health care operations, appointment reminders, as required by law, to avert a serious threat to health or safety, to military command authorities, to law enforcement, for public health risks, for workmen’s compensation, as ordered by a court, to coroners, and to national security agencies.

Your rights regarding your privacy:
You have the right to inspect, copy (copying fees apply), and amend your health information. You have the right to request a reasonable restriction or limitation on the health information I use or disclose about you for treatment, payment, or health care operations. You have the right to request confidential communication. All of the above requests must be made in writing and submitted to Fluid Manual Therapy, LLC. I will accommodate all reasonable requests. If you feel your privacy has been violated, you have the right to file a complaint with the Department of Health and Human Services. The complaint in no way influences your course of treatment with Karen Swift, MSPT.

Acknowledgement of Receipt of this Notice:
I am required to supply you with a copy of this privacy policy and your signature on the consent form acknowledges that you have received it.
Insurance Reimbursement
I do not directly bill insurance companies. However, I can provide you with a bill that includes the procedure codes for physical therapy if you are able to submit these bills. Please let me know if you plan to do this so I can document appropriately. Should your insurance company require extra written reports, I will need to charge for this service. Please note that I am not a Medicare Provider. This means that your secondary insurance company will not cover my service fees.

Please can you wear or bring some comfortable clothing that is appropriate for physical movement. Leggings or shorts work well. Please do not wear jeans, dresses, or shirts with strong stripe or polka dot patterns. To respect those with chemical sensitivities, please can you avoid wearing perfumes to the studio.
If anything is unclear, please call me at (505) 401.8206. I look forward to working with you.

Medical Questionaire

Informed Consent

Policies and Procedures