THE PRACTICE -Northern Virginia Hand Therapy Center, LLC and/or its therapists, employees, agents or assignees will hereafter be referred to as “The Practice”.

CONSENT FOR TREATMENT -The undersigned hereby consents to the administration of such medical treatment, diagnostic and/or therapeutic procedures as required by The Practice rendering care for themselves and/or their child(ren).

AUTHORIZATION & ASSIGNMENT OF INSURANCE BENEFITS -I do hereby authorize The Practice to apply for benefits for services rendered to myself or minor child(ren) under any health insurance policies/programs providing benefits and do hereby also assign and authorize payment of benefits from my (our) insurance company to The Practice. I authorize The Practice to contact the employer or insurance company regarding insurance information, existence of insurance and coverage of my (our) benefits.

RELEASE OF MEDICAL INFORMATION -I authorize The Practice to release any and all of my or my minor child(ren)’s medical records and/or other information and records required by my (our) insurance company or its designated review agents who provide insurance benefits on my (our) behalf, including if applicable, my employer and/or employer’s workman’s compensation insurance company, the Social Security Administration, or the Centers for Medicare and Medicaid Services, needed to determine benefits and to process insurance claims and secure payment of benefits to either the insured or to The Practice; and authorize any hospital, lab, physician, or other healthcare provider and/or their staffs to release my or my minor child(ren)’s medical records and/or other records and information on myself or my minor child(ren) to The Practice as required for payment of benefits and/or required for medical or any other reasons; and authorize The Practice to release the above mentioned records for any of the above reasons. I agree to pay any applicable charges for having medical records copied.

REFERRALS AND AUTHORIZATIONS -I understand that it is my responsibility, if I (we) have an insurance plan that requires any referrals, pre-certifications or authorization to receive any additional medical services, such as specialty care, to obtain such authorization from The Practice or insurance company prior to such non-emergency services being rendered. Additionally, if any aforementioned procedures are not done, I understand that this may cause reduced or rejected coverage for which I will be held responsible and that any of these aforementioned actions do not guarantee that my insurance company will pay for my (our) child(ren)s claims. Any denial of claims is between the policyholder/subscriber and their insurance. I (we) agree to inform The Practice immediately of any change in insurance coverage and/or benefits and change of personal information.

FINANCIAL AGREEMENT -I agree that payment in full is due at the time of treatment. I, the undersigned (jointly and severally if more than one) further agree that I am legally obligated and responsible and do hereby guarantee payment for all charges incurred by myself, my spouse, my children, step-children or any other extended family members, including but not limited to grandchildren, nieces and nephews. The Practice will file for insurance benefits and accept payments per The Practice’s contractual agreements with the insurance company. Any questions or disputes concerning insurance coverage or payment of benefits is a matter between the insurance subscriber/policyholder and the insurance company. Any assistance in this matter granted by The Practice is given strictly as a courtesy and implies no responsibility on The Practice’s part for filing, follow through or conformation. Should any balances arise due to insurance co-payments, co-insurance, deductibles, non- covered services/procedures, termination of coverage, not adding a dependent to insurance plan, non-payment at time of service and/or any other reason I agree to pay all charges within 30 days of services rendered. I agree that if for any reason a check is returned on my account I will be responsible for a $35.00 returned check fee in addition to the original fees for services. If the balance is not paid within the 30 days or if agreed upon payment arrangements on my (our) account are not made, I authorize the practice to charge any payment method I may have on file in order to satisfy any overdue balances, I am also aware that the practice has the right to retain the services of an attorney and/or collection agency to assist with the collection of any outstanding balance and to notify the credit bureaus of my (our) delinquencies. I understand that this will affect my (our) credit rating. If this account is placed for collection, I agree that any expenses incurred by such collection actions, including maximum allowed service charge, shall become an additional liability for which I (we) assume full responsibility.

COPY OF SIGNATURE -I permit a copy of this authorization and signature to be used in place of this original on all insurance claim submissions and for the release of any medical records and/or other records and information, as stated herein, whether manual, electronic or telephonic.

CERTIFICATION -I certify that the information I have reported with regard to my (our) insurance coverage is correct and that the above be honored by my (our) insurance carriers.I also certify that I have read the foregoing and as the parent/guardian/guarantor understand and fully accept the terms therein.

Effective as of January 1, 2019

We at NOVA Hand Therapy Center realize circumstances might cause you to miss a scheduled appointment. However, to provide the best care and service to each patient, we ask that you notify us 24 hours in advance to cancel your appointment. We will be more than willing to reschedule your appointment for a different time on the scheduled day OR within 24 hours.

Please be advised that failure of proper notification will result in either a Last Minute Cancellation Fee of $50.00 or a No Show Fee of $65.00.

We value our patient/therapist relationships and will do everything we can to accommodate you. Your communication and compliance are not only very much appreciated but will help you (and others) achieve a positive outcome.

The goal at NOVA Hand Therapy Center is to provide you with caring and effective treatment. To fully benefit from therapy, we would like you to become familiar with our services, to know what you can expect from us and what we expect from you.

PHILOSOPHY OF CARE

  • Our goal is to empower you with knowledge. By fully understanding your condition, you will be better able to participate in your own recovery. Feel free to ask questions about your diagnosis or treatment. We strive to create a relaxed and supportive environment. Please let us know how we can make you more comfortable.

TREATMENT

  • In order to fully benefit from therapy, it is important to attend therapy sessions consistently and perform your home program as prescribed by your therapist.
  • If you feel therapy is not meeting your needs, please bring it to our attention. We’ll be happy to modify your program to ensure a successful recovery.

UPCOMING APPOINTMENTS AND ATTENDANCE

  • Please arrive on time for your appointments. If you are more than 15 minutes late, your appointment may need to be rescheduled.
  • For treatment to be effective and covered by insurance, it is important for you to be treated consistently. If you are unable to attend an appointment, please call us at least 24 hours in advance to cancel and reschedule (preferably within the same week).
  • Missing more than three scheduled appointments without advance notice may result in scheduling your appointments on a day-to-day basis or cancellation of future scheduled appointments.

FOLLOW-UP VISITS WITH YOUR PHYSICIAN

  • We periodically assess your progress and send reports to your physician. Please advise us of all upcoming appointments with your physician.

CHILDREN

  • We understand that childcare is not always possible. If you are unable to have your child cared for during your next appointment, we would appreciate if you could bring a responsible family member or friend to watch your child in the waiting room. Our staff is not permitted to provide childcare.
  • If you are unable to find suitable accommodations, please discuss this matter with us.

INSURANCE

  • It is your responsibility to verify that hand therapy is covered by your insurance carrier. Please note that hand therapy is billed under either occupational or physical therapy when checking with your insurance company.
  • It is also important to determine the number of visits and/or the dollar limit permitted in a calendar year.
  • As a courtesy, within a week of your first appointment, our front office staff will contact your insurance company to verify therapy eligibility and benefits. If your insurance company requires prior authorization, please ensure that this has been addressed by your physician/practitioner’s office.

We can be reached at 703-544-7171. If calling after hours, please leave a message on our voicemail. We will contact you as promptly as possible.

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