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Patient Name
Name of Person Completing This Form if Other Than the Patient
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Welcome
Thank you for choosing LifeCare for your therapy and rehabilitation needs. We know that you have choices when it comes to your healthcare, and we will strive to meet and exceed your expectations in the therapy and customer service that we provide to you. Please read this document in its entirety and sign the last page of the document to acknowledge your understanding and receipt.
Contact Information
We welcome your comments, compliments and concerns and are happy to provide you with any additional information. Please contact us at any time.
Admissions/Patient Coordinator: Ashley Jacobetti
Fax: 561-409-0876
Email: [email protected]
Office: 561-291-7922
Scheduling Your Therapy Appointments
You will have a therapist, or a team of therapists, assigned to your care who will schedule therapy appointments directly with you. If you do need to cancel an appointment, please give as much advanced notice as possible. While we do understand that occasional cancellations are inevitable, frequent cancellations are disruptive to your care and to your therapist who has set the time aside exclusively for your treatment. We appreciate your consideration in this matter.
Your therapist(s) will provide you with contact information so you can reach and schedule with your therapist(s) directly.
Remote Therapeutic Monitoring
LifeCare is pleased to include Remote Therapeutic Monitoring in our patients' care plans. Remote therapeutic monitoring is a system in which your therapist will be able to connect with you, the patient, or a family member/caregiver through daily text messages. This service:
- Lets your therapist monitor your progress outside of your therapy sessions.
- Allows you to ask questions and share information with all of the members of your therapy team.
- Gives motivation to follow through with the home exercise program.
The system works through direct text messaging to a mobile phone or flip phone. Your therapist(s) will explain more but enrollment will begin after your first treatment session.
Outpatient Therapy Benefits
Financial Responsibility
Whether you are a new client or a returning loyal patient of LifeCare (welcome back!), we want to be sure you understand the cost of care. LifeCare Therapy Services is an accredited Medicare provider and an in-network provider for United HealthCare. Your therapy can also be covered by a PPO Plan with out of network benefits and many long term care plans. We will verify your insurance coverage before start of care and will bill your insurance directly. In many cases, if you have a co-insurance, Medicare will pay 80% and we will bill your secondary insurance carrier, or you, for the remaining 20%.
If you do not have insurance or do not want to use insurance for therapy care, private pay options are also available. If you do not have insurance, choose not to use your insurance or choose to receive out of network care, you have the right to a Good Faith Estimate before care is started.
If you have questions regarding your coverage and any out-of-pocket expenses, please speak directly to the office who will have the most accurate information.
Please also take notice that LifeCare of Florida is certified by Medicare as an outpatient therapy provider and works under a unique "mobile clinic" model. If you require Part A home health therapy or nursing needs, LifeCare services will not be covered. Examples of services that may be provided under home health including nursing services, wound care, lymphedema care and some paid home health aide services. If you begin any of these services, please notify our office so we can determine if your care is still covered or if we need to place services on hold.
Acknowledgement of Financial Responsibility
By your signature on that end of this document, you are acknowledging your agreement to the following:
- I understand that any changes to my insurance could affect my financial responsibility and I will notify LifeCare if there is a change to my primary or secondary insurance coverage.
- I understand and acknowledge my financial responsibility for any co-payments, deductibles, out of pocket or co-insurance costs that are not covered by my insurance policy.
- I request payment of authorized Medicare benefits to me or on my behalf for any services furnished me by LifeCare Therapy Services. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services.
- I understand that if payment is directed to me, it is my responsibility to forward this payment to LifeCare.
- Should this account go delinquent, I agree to pay all costs of collection including collection agency fees, court costs and attorney fees.
Informed Consent for Treatment
Serving South Florida since 2004, LifeCare Therapy is a Medicare Part B certified clinic providing one-to-one outpatient Physical, Occupational & Speech-Language Therapy services to patients in their home, our clinic in Tamarac, FL or a location of your choice including daycare centers, ALFs, ILFs, and more. Our mobile therapy team serves patients throughout Miami-Dade, Broward, Palm Beach, Port St. Lucie & Martin counties. All therapy services that we offer are provided by therapists who are licensed and have completed background screening requirements. We provide therapy under a doctor’s written orders who will also be given a copy of the therapy plan of care to review and certify.
Response to a specific treatment can vary widely from person to person so it is not always possible to accurately predict your responses to a certain therapy modality or procedure. Please understand that we are not able to guarantee precisely what your reactions to a particular treatment might be, nor can we guarantee that our treatment will help the condition you are seeking treatment for. There is also a risk that your treatment may cause pain or injury or may aggravate previously existing conditions. You have the right to ask your therapist what type of treatment he or she is planning based on your history, diagnosis, symptoms and testing results. You may also discuss with your therapist what the potential risks and benefits of a specific treatment might be. You have the right to decline any portion of your treatment at any time or during your treatment session. While we know that these risks exist, we will conduct the initial therapy evaluation and provide you with our expert recommendations for you to be able to make an informed decision.
Treatment Verification
In order to verify the time your therapist has spent with you, therapists will be using their phone or computer to "check-in" and "check out" through HUCU. HUCU is a HIPAA-compliant messaging program that is shared by your therapy team to be able to communicate with one another. HUCU provides a time stamp and geo-locator for the therapy session. If there is difficulty logging in, you will be asked to sign a Treatment Verification Log for the visit. Please be sure that the date, start- and stop times are accurate and please never sign a “blank” log or a log when you did not receive therapy services. If you have any concerns, please notify our Admissions Department immediately.
In certain situations, a patient may not be able to physically sign a treatment note. In these cases, LifeCare of Florida asks that a person or persons be identified who can sign the treatment note on the patient’s behalf. This signature is solely to acknowledge receipt of therapy and does not authorize the person to act on the patient’s behalf in any other manner.
Notice of Privacy Practices
In compliance with the Health Insurance Portability and Accountability Act (HIPAA), and Health Information Technology for Economic & Clinic Health (HITECH), LifeCare has a Notice of Privacy Practices which provides detailed information on how we may use and disclose Protected Health Information about you. You have the right to review our Notice before signing this consent and prior to any service being provided to you by LifeCare of Florida. LifeCare reserves the right to change this Notice and, if we do change this notice, you have the right to obtain a revised copy on your request. You also have the right to revoke any Consents given provided that you do so in writing. Please note that a revocation cannot affect any disclosures we have already made.
LifeCare will release your Protected Health Information to your physician(s) and will also use your information for LifeCare treatment, payment, and operations. If you would like information released to other individuals or companies, please contact our office and a HIPAA Authorization Form will be given to you.
Authorizations & Informed Consent
Name
Financial Responsibility
Informed Consent for Treatment
HIPAA Privacy
Treatment Verification
For this episode of care, please select one of the following choices:
Individual(s) authorized to sign the Treatment Logs
Power of Attorney
Please check if applicable
