Notice of Privacy Practices (available on https://www.onpointmvp.com/notice-of-privacy-practices.html)
I acknowledge receipt of the Notice of Privacy Practices from On Point Movement & Performance, DBA. I understand that the Notice of Privacy Practices provides information about how On Point Movement & Performance, DBA may use and disclose my protected health information. I have reviewed it and understand that the Notice of Privacy Practices is subject to change. If the Notice is changed, I may request a revised copy.
Consent for Treatment
I hereby consent to such treatment procedures and patient care which, in the judgment of my therapist and/or physician, may be considered necessary or advisable while I am a patient of On Point Movement & Performance, DBA.
Guarantee of Account
I hereby guarantee payment for any services rendered to me which are not covered or allowable by Medicare, together with collection costs, including reasonable attorney fees. I also understand that all bills are due and payable upon presentation. I understand that the client’s responsibility portion of my bill shall
be due and payable at the time of services. I understand that I am personally responsible for full payment of all charges including Medicare denials, deductibles, and copayment fees. I understand that On Point Movement & Performance, DBA does not submit to any other insurances, unless negotiated with before the start of service. I understand that I will be provided with an invoice for services not covered by Medicare in which I can submit to my own insurance for reimbursement. in consideration of services rendered to me by On Point Movement & Performance, DBA
Medicare/Insurance
I hereby certify that my information in applying for payment under title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any such information needed for this or a related Medicare/Insurance Claim. I request that authorized benefits be paid on my behalf. I understand that I am responsible for any health insurance deductibles and co-insurance. I understand that I cannot receive Medicare Part B services in the home if I am currently on Home Health under Medicare Part A, and or on Hospice Care. I understand that services must be skilled and medically necessary to be covered by Medicare Part B. I understand Medicare will pay for 80% of the allowed amount, and I am responsible for the remaining 20% (Good Faith Estimate is $25-$30 per visit) if I do not have secondary insurance or if my secondary insurance does not cover the 20% due to policy limitations. Insurance Good Faith estimate: not to exceed more than $250 per visit.
Cancellation Policy
I understand cancellations should be made 24 hours (48 hrs on weekends) in advance. If not, a $70 cancellation fee will be billed to the card on file.
Home Health
While under Medicare Part B, I understand that I cannot receive home health, hospice, or hospital services as Medicare Part A services, and the patient will be financially responsible if I have not confirmed that I have been discharged from Part A services.
Release of Information
I hereby authorize the release of any information by telephone, email/fax, or in writing, including reports of diagnosis, treatment prognosis, recommendation, as well as any other data pertinent to my treatment, by On Point Movement & Performance, DBA, to the physician who referred me for therapy. I also authorize the release of any information by telephone or in writing for utilization and quality review purposes.
Important Note:
This benefits verification is a complimentary service provided by On Point. It is ultimately the patient’s responsibility to understand their coverage and any costs associated with their treatment. The provided estimates are based on information received from your insurance provider and are subject to change. For the most accurate and up-to-date information, please contact your insurance company directly.