The privacy of your personal information is important to our clinic. We are committed to collecting, using and disclosing personal information responsibly and only to the extent necessary for the goods and services we provide.
Like all medical professionals, we collect, use and disclose personal information in order to serve our patients. The primary purpose for collecting personal information is to provide treatment.
Like most organizations, we also collect, use and disclose information for purposes secondary to our primary purposes. The most common examples of our related and secondary purposes is to invoice patients for goods or services that was not paid for at the time, to process credit card payments or to collect unpaid accounts.
The cost of goods/services provided by the organization to patients is often paid for by third parties (e.g., motor vehicle accident insurance, private insurance). These third party payers often have the patient’s consent or legislative authority to direct us to collect and disclose certain information in order to demonstrate patient entitlement to this funding.
Patients or other individuals we deal with may have questions about our goods or services after they have been received. We retain patient information for a mandatory minimum of ten years after the last contact.
PROTECTING PERSONAL INFORMATION
We understand the importance of protecting personal information. For that reason, we have taken the following steps:
• Paper information is either under supervision or secured in restricted area.
• Electronic hardware is either under supervision or secure in a restricted area at all times.
• Paper information is transmitted through sealed, addressed envelopes or boxes by reputable companies.
• Electronic information is transmitted either through a direct line or has identifiers removed or is encrypted.
• External consultants and agencies with access to personal information must enter into privacy agreements with me.
YOU CAN LOOK AT YOUR INFORMATION
With only a few exceptions, you have the right to see what personal information we hold about you.
We can help you identify what records we might have about you. We will also try to help you understand any information you do not understand (e.g., short forms, technical language, etc.). We reserve the right to charge a nominal fee for such requests.
The undersigned understands and agrees to the following:
Most private and/or employer-funded insurance plans include an annual deductible. A deductible is the amount a patient must pay out-of-pocket before the private insurance company will make payments toward claims. A deductible can vary from $0-$5000 or more.
**It is the patient’s responsibility to both understand the deductible amount and pay any portion of a claim not paid by the insurance company.
Most private and/or employer-funded insurance plans also include a co-pay or co- insurance amount. A co-pay is a set amount that the patient must pay for each visit. If your plan includes a co-pay it will generally be listed on your insurance card. The co-pay that applies to our service will be listed as office visit or O/V. If there is no co-pay listed it is likely that your plan has a co-insurance amount. Co-insurance is a percentage of the allowed amount (the agreed rate your insurance company pays your provider) that the patient is responsible for.
Deductible, co-pay and co-insurance amounts will be calculated after we complete the billing of your insurance company. We bill weekly, however please note that insurance companies may take 14-60 days to pay on any given claim. Once we receive payment on your behalf we will email you a statement of the balance due, and expect a reply to this email in the form of payment or authorization to bill your credit card on file.
**Any balance over 30 days old, for which we have sent you a statement, will automatically be billed to the card on file. If that transaction fails, late fees will be assessed.
All insurance-billed massage requires that the patient have a valid prescription for massage therapy on file that covers all dates of service. The specifics of what should be on this prescription are listed in the FAQ on our website: www.intuitive-bodywork.com.
Amounts invoiced to you, as well as maintaining a current and valid prescription and having knowledge of the terms of your insurance plan (such as how many massage therapy treatments are covered) are the patient’s responsibility. If your insurance company does not pay for any reason you will be billed for that date of service.
I understand and agree to these terms