Massage Intake Form from Achieve Physical Therapy

Personal information

Health History

Consent Relating To Treatment Of A Minor Patient

1. I am a parent or legal guardian of the Minor Patient authorized to make health care decisions on behalf of the minor Patient.
2. I authorize APTSM to engage in the following acts: (Please check all that apply)
   Direct Authorization for Treatment by APTSM

   OffOn

   I authorize APTSM to provide the Minor Patient with emergency, urgent and other medical care and treatment in my absence. (This allows a minor patient to come to an appointment(s) unaccompanied by parent/guardian/parent substitute.)
   Appointment of Parent Substitute to Authorize Care and Treatment for Minor Patient

   OffOn

   I authorize the Parent Substitutes designated below to give informed consent for emergency, urgent and other medical care and treatment for the Minor Patient
   Release of Information

   OffOn

   To ensure that the Patient Substitute has access to Protected Health Information needed to make informed consent decisions, I authorize APTSM to provide the Parent Substitute with Protected Health Information - this means all medical records and treatment records relating to the Minor Patient which are protected and confidential under 42 C.F.R. Part 2, Wis. Stat. sections 51,30 and 146.82, the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 ("HIPAA"), and the Standards for Privacy of Individually Identifiable Health Information ("HIPAA" Privacy Regulations), 45 C.F.R. Part 160 and Part 164, subparts A and E.

3. Identification of Parent Substitutes I appoint the following Parent Substitute(s) to obtain access to Protected Health Information, give informed consent for care and treatment, or otherwise receive custody of the Minor Patient.

   Parent Substitute 1:

   Name

   Relationship

   Phone

   Parent Substitute 2:

   Name

   Relationship

   Phone

   Parent Substitute 3:

   Name

   Relationship

   Phone
4. Duration This authorization is valid for a maximum period of two (2) years from the date signed, unless a shorter duration is specified below. This authorization may be revoked at any time prior to that expiration date by providing APTSM with written notice. Please send the written notice to Privacy Officer, Achieve Physical Therapy and Sports Medicine, 106 S. Holmen Drive, Holmen, WI. 54636.
   Start Date
   End Date
5. Release I agree to release APTSM from liability for any claims resulting from APTSM's provision of patient care and release of Patient Health Information in reliance upon this authorization.

Agreement

For the sake of privacy and dignity, draping is used during the session – only the focus area will be uncovered. For clients under the age of 17, an informed written consent must be completed by the parent or guardian prior to the initiation of the session and he/she must be accompanied by a parent or legal guardian for the duration of the massage.

I, understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

To cancel an appointment, please call our office as soon as you know you are unable to keep your scheduled time, but at least 24 hours in advance. Absences will be noted as excused or unexcused. Excused absences consistent of cancellations 24 hours or more in advance and those cancellations due to weather or illness. If there is one unexcused absence and you wish to schedule another appointment, you will be asked to pay ahead. That massage fee will then be non-refundable unless cancelled 24 hours or more in advance. Should you arrive late to you appointment, the therapist will not be able to do a complete visit, but you will be charged for the entire time scheduled.

Patient Bill of Rights

The Right to Information

Patients have the right to receive accurate, easily understood information to assist them in making informed decisions about their health plans, facilities and professionals. Patients have the right to receive assistance from providers if they have difficulty understanding information, if they speak a different language, or have a physical or mental disability.

The Right to Choose

Patients have the right to a choice of health care providers that is sufficient to assure access to appropriate high-quality health care including giving patients with serious medical conditions and chronic illnesses access to specialists. Each patient has the right to request names and functions of all health care personnel having direct contact with the patient.

Access to Emergency Services

Patients have the right to access emergency health services when and where the need arises. Patients who have severe pain, an injury, or sudden illness that is convincing that one’s health is in serious jeopardy, have the right to receive screening and stabilization emergency services whenever and wherever needed, without prior authorization or financial penalty.

Being a Full Partner in Health Care Decisions

Patients have the right to fully participate in all decisions related to their health care. Consumers who are unable to fully participate in treatment decisions have the right to be represented by parents, guardians, family members, or other conservators. Health professionals have a responsibility to discuss and advise patients on medically necessary treatment options. Except in emergencies, each patient has the right to have their provider obtain the patient’s informed consent prior to the start of any procedure or treatment for which informed consent is required, in accordance with the Health Care Services Malpractice Act. Patients have the right to full information and counseling on the availability of known financial resources for payment of their health care. Each patient has the right to examine and receive a detailed explanation of their bill, regardless of the source of payment for their care.

Care Without Discrimination

Patients have the right to considerate, respectful care from all members of the health care industry at all times and under all circumstances. Patients must not be discriminated against in the marketing or enrollment or in the provision of health care services, consistent with the benefits covered in their policy and/or as required by law, based on race, ethnicity, national origin, religion, sex, age, current or anticipated mental or physical disability, sexual orientation, genetic information, or source of payment.

The Right to Refuse Treatment

To the extent permitted by law, each patient has the right to refuse any drugs, treatment, or procedure offered by the provider, and to be informed of the medical consequences of their refusal.

The Right to Privacy

Patients have the right to communicate with health care providers in confidence and to have the confidentiality of their individually-identifiable health care information protected. Patients also have the right to review and copy their own medical records and request amendments to their records.

The Right to Speedy Complaint Resolution

Patients have the right to a fair and efficient process for resolving differences with their health plans, health care providers, and the institutions that serve them, including a rigorous system of internal review and an independent system of external review.

Statement of Patient Responsibilities

In a health care system that affords patients rights and protections, patients must also take greater responsibility for maintaining good health. This includes, but is not limited to, providing timely, accurate, and complete information to providers; working respectfully with all staff and providers; asking questions if instructions, orders, or procedures are not understood; and assuming financial responsibility for all services rendered.

Notice of Privacy Practices

This notice describes the practices of Achieve Solutions Inc. (ASI) doing business as Achieve Physical Therapy Sports Medicine. Please review this carefully as it pertains to the privacy of your health information as it relates to:

• Any health care professional authorized to enter information into your patient chart
• All departments and units of Achieve Solutions Inc. and APTSM
• Any member of a volunteer group we allow to help you while you are in an APTSM facility
• All employees, staff, and other Achieve Solutions Inc. and APTSM employees

This notice also describes the practices of Achieve Solutions Inc. (ASI) when they are rendering care at the home or living facility of the patient.

Our Pledge Regarding Medical Information:

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at any APTSM clinic, or care and services APTSM may provide in your place of residence. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by ASI, whether made by ASI personnel or therapist. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligation we have regarding the use and disclosure of medical information. We are required by law to:

• Make sure that medical information that identifies you is kept private
• Give you this notice of our legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of the notice that is currently in effect.

How We May Use & Disclose Medical Information About You

The following categories describe different ways that we may use and disclose medical information. For each category of uses or disclosures we will explain what we mean and try to give some examples. This is not to infer that these are the only situations where we may need to share/disclose information about you. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. We follow the Wisconsin state law for informed consent for treatment.

For Treatment: We may use medical information about you to provide you with medical treatment and services. We may disclose medical information about you to physicians, nurses, technicians, medical students, or other ASI personnel who are involved in taking care of you. For example, a therapist treating you for a broken leg may need to know that you have diabetes because diabetes may slow the healing process. In addition, the therapist may need to disclose this information to a nurse who may be checking on the status of your incision. We also may disclose medical information about you to people outside of APTSM/ASI who may be involved in your medical care after you are discharged. Under no circumstances will APTSM/ASI share protected health information with non-healthcare providers (i.e. family members, clergy, friends) unless we have your verbal and/or written consent. Friends and family often play a critical role in providing care between visits or when therapy services have been completed. For this reason there may be times when we seek your permission to disclose protected information.

For Payment: We may use and disclose medical information about you so that the treatment and services you receive at APTSM/ASI may be billed to: you, your insurance company, or third party provider. For example, we may need to provide information to your insurance company about therapy services received at our clinic for proper payment and reimbursement. We may also need to share information with your health plan about current progress and future treatments to obtain prior approval and coverage for reimbursement. If you choose to pay for services in their entirety by cash and not by billing your insurance, you may instruct ASI not to share information with your health plan.

For Health Care Operations: We may use and disclose medical information about you for APTSM/ASI operations. These uses and disclosures are necessary to Achieve Physical Therapy and Sports Medicine quality assurance programs. For example, we may use medical information to review our treatment and services and to evaluate the performance of the staff in caring for you. We may also combine medical information about many patients to help evaluate what additional services we should offer, what services are not needed, and whether certain treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other APTSM/ASI personnel for review and learning purposes or for follow-up of a complaint or care issue. We may also combine the medical information we have with medical information from other health care facilities to compare how we are doing and see where we can make improvements in the care and services we offer. Every attempt will be made to remove identifying information, so others may use it to study health care and health care delivery without learning who the specific patients are.

For Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or evaluation at Achieve Physical Therapy and Sports Medicine clinic or locations.

Treatment Alternatives: We may use and disclose medical information, with your express permission, to tell you about or recommend possible treatment alternatives or options that may be of interest to you.

Health-Related Benefits and Services: We may use and disclose medical information, with your express permission, to tell you about health related benefits or services that may be of interest to you. We will ask for your express permission if any of your health or personal information would be used for marketing or fundraising purposes. Your health and personal information will never be sold without your express permission.

Patient Schedule/Directory: We may include certain limited information about you in the patient schedule/directory while you are an active patient in the clinic. The information may include your name, location of the facility, your general condition (fair, stable, etc…) This schedule/directory is for APTSM/ASI internal use only or to confirm with other primary healthcare providers that you have an appointment. This information will not be shared with non-healthcare providers unless we have your written/verbal approval.

Individuals Involved in Your Care or Payment of Your Care - With Your Permission: We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends you condition and that you are receiving treatment in a rehabilitation clinic. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your location, status, and condition.

Research: Under certain circumstances and with your express permission, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing patients who received one type of therapeutic intervention with those who received another type of therapeutic intervention for the same condition. Please note that all research projects are subject to a special approval process. We will always ask for your specific permission prior to sharing protected healthcare information with a researcher. As an added protection, only institutional review board (IRB) reviewed and approved research will be conducted at APTSM facilities. This ensures an added level of protection to our clients and their health information. APTSM and ASI do reserve the right to use outcomes and data that has no connection to an individual patient and does not disclose protected healthcare information. An example would be using range of motion data to assess outcomes following a total knee replacement.

To Avert a Serious Thread to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to you/public health and safety. Any such disclosure, would only be to someone able to assist in relieving or preventing the threat.

Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate military authority. We may use and disclose to components of the Department of Veteran’s Affairs medical information about you to determine whether you are eligible for certain benefits.

Workers' Compensation: APTSM after having received a valid request for information, may release medical information about you for workers’ compensation or similar programs. The programs provide benefits for work-related injuries or illnesses. An example would be a representative from your workers comp plan makes a formal request to review your therapy progress notes.

Public Health Risks: We may as required by law, disclose medical information about you for public health activities. These activities generally include the following:

• To prevent or control disease, injury or disability
• To report child abuse or neglect
• To report births or deaths
• To report reactions to medications or problems with products
• To notify people of recalls of products they are using
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensures. These activities are necessary for the government to monitor the health care system, government programs and compliance of civil rights.

Lawsuits and Disputes: If you are involved in a lawsuit or dispute, APTSM and ASI will only disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute following all appropriate rules.

Law Enforcement: Under the following circumstances we may release information to a law enforcement official:

• In response to a court order, subpoena, warrant, summons, or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person
• Involving the victim of a crime, such as abuse or assault.
• About a death we believe may be the result of criminal conduct
• About criminal conduct at APTSM/ASI that requires release of your protected health info;
• In emergency circumstances to report a crime; the location of a crime or victims; to the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors: PTSM may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of APTSM to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities APTSM/ASI may release medical information about you to authorized agents or federal officials so they may provide protection to the President, or other public official. Or use the information to protect the public health and/or prevent an act of terrorism. This information will only be released to persons authorized to conduct these special investigations.

Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, APTSM may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional facility.

Your Rights Regarding Medical Information:

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. You have the right to request your medical records in paper or electronic form. In order to inspect and copy medical information pertaining to you, you will need to submit a written request to:

If you request a copy of the information, APTSM/ASI may charge you a fee to pay for the cost of copying, mailing, or other supplies associated with your request. If there is reason to deny your request, you have the right to appeal. If you choose to appeal another licensed health care professional chosen by APTSM/ASI will review your request and denial. The healthcare professional conducting the review will make an independent determination about your request and we will comply with the outcome of the review.

Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by APTSM / ASI. The request for amendment must be submitted in writing to:

Please include a reason and as much documentation as possible that supports your request. Any amendment made is included as an addendum to the original record. The original content cannot be altered, but the addendum can reflect the requested changes. We may deny your request for an amendment if you ask to amend information that:

• Was not created by APTSM/ASI
• Is not part of the medical information kept by or for APTSM/ASI
• Is in any way false or misleading, or attempts to conceal a health condition or behavior
• Is deemed accurate and complete

Right to an Accounting Disclosure: You have the right to request an “accounting disclosure”. This is a list of the disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to:

Your request must include a specific time period (from MM/DD/YY to MM/DD/YY) and may not include dates prior to March 1st, 2007. Your request should indicate in what form you wish to receive the information (on paper, electronically). Patrons of APTSM will be allowed one “accounting disclosure” free of charge. Further requests made within 12 months of the previous request will be charged a fee to cover the cost of producing each additional list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time.

Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend. For example, you could ask that we not use or disclose information about the type of injury you have to your spouse who brings you to therapy. APTSM will make every attempt to honor your request but are not required to do so if such a request is in conflict with the previously stated reasons for disclosure. If we do agree, we will comply with your request unless the information is needed to provide information for emergency treatment. To request restrictions, you must make a request in writing to:

As part of your formal request please include the following 1) tell us what information you would like to limit, 2) whether you want to limit our use, disclosure, or both; and 3) to whom you want the limits to apply, for example disclosure to your spouse.

Right to Request Confidential Communications You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we only contact you at work or by mail. To request confidential communications, you must make your request known during your initial visit at APTSM. If the confidential communication is in reference to a previous period of treatment, you can submit your request in writing to:

We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice: You have a right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have asked for an electronic copy of this notice, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, please contact:

Changes to this Notice: We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the clinics of Achieve Physical Therapy and Sports Medicine (APTSM) and Achieve Solutions Inc (ASI). In addition, each time your register, or are admitted for treatment we will offer you a copy the current privacy notice.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with APTSM/ASI, or with the Secretary of the Department of Health and Human Services. To file a complaint with APTSM/ASI please submit your complaint in writing to:

Filing of a complaint will not affect your care or treatment with APTSM/ASI.

Breach Notification ASI makes every effort to safeguard protected health and personal information. Should a breach of information be suspected to occur, ASI will perform a full investigation. When a breach is discovered, we will notify each affected individual by first-class mail, or, if the individual has agreed, by e-mail. This notification will be done as quickly as feasible, within a maximum of sixty (60) days after the discovery of the breach. ASI will follow Federal guidelines to resolve any and all breaches of information to protect the individuals we serve.

Other uses of Medical Information: Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care we provide to you.

If you have questions regarding this notice, please contact Achieve Physical Therapy and Sports Medicine/ Achieve Solutions (608)526-9888.