Policies

Good standing: Patients in good standing are respectful and professional, cooperative with treatment, compliant with prescribed home exercise program, and Therapist instruction. No outstanding balance from late cancellations/no-shows.

• All outstanding balances including late cancellation/no shows paid at next scheduled appointment. Treatment balances must be paid in full within one month to the date of statement.
• Patients must maintain good standing in order to receive treatment at ESPT.

Poor standing: Patients who are not respectful, behavior is unprofessional, and negative towards any member of the ESPT staff or to any patients. Patients who are not cooperative with treatment, patients with overdue balances will not be tolerated. Patients exhibiting such behavior may be subject to delay of treatment, discharge from treatment, and/or exited from ESPT.

Discontinuation of Care: If for whatever reason you need to discontinue PT services, it is your responsibility to notify ESPT as soon as possible. You will be responsible for any no-show or late cancellations fees acquired.

Patient cooperation: We expect all our patients to cooperate in treatment, follow prescribed exercises, and follow medical instruction in order to progress and improve. Failure to follow HEP/instructions will result in minimal to no progression.

Updating contact information: Please verify all contact information including legal name, home address, phone number, and email address. Any changes to personal information must be notified to front desk.

Cancellations: We ask all patients to make cancellations 48 hours in advance as a courtesy to other patients who may be interested in the appointment. Cancellations can be made at an earlier appointment, or by phone/email.

Cancellation within 48 hours of appointment: ESPT has a strict late cancellation policy. A cancellation made within 48 hours notice will result in a $75 late cancellation fee. Late cancellation fee must be paid at time of next visit in order to keep your next scheduled visit. Work-related reason for late cancellation is still subject to late cancellation policy – patients may ask their employer if reimbursement is available.

No-show/Missed Appointments: We have a strict no-show policy which results in a $75 fee for a missed appointment. You must pay the no-show fee at time of your next appointment in order to keep your next scheduled appointment. Missed appointments may be pardoned due to sickness with doctor’s note only.

Consecutive No-Shows: Two consecutive no-shows will result in an automatic discharge from care, including $150 accumulated no-show fee and you may be placed under poor clinic standing until all outstanding balances are paid up-to-date. In order to resume PT treatment and return to good standing, all outstanding fees must be paid.

Late Arrival to Appointment: Late arrival constitutes 15 minutes beyond scheduled appointment time. It is per the discretion of the physical therapy provider to continue with treatment. Arrival 20+ minutes beyond scheduled appointment time will result in an appointment forfeit and $75 fee for missed appointment.

Contacting The Clinic: We do our best to answer all phone calls, however we give priority attention to patients in the clinic who require assistance. Please leave a voice message or email us at frontdesk.ESPT@gmail.com and we will return your call/email. We will not be able to return your call unless a message is placed.

Contact information:

• Phone number: 510-656-3777
• Fax number: 510-656-3750
• Email: Frontdesk.ESPT@gmail.com

Failure to respond to ESPT communication: When we notice repeated cancellations or a missed appointment, we will likely call you to confirm your next appointment and also ask if you plan to continue care. If you do not respond to our requests, we may close your case and cancel remaining appointments. Any late cancellations or no-show fees incurred will be your responsibility and all balances will need to be paid up-to-date in order to resume care.

Scheduling Appointments: Appointments can be scheduled over the phone or by email

Re-Scheduling Appointments: Re-scheduling appointments can be made over the phone or by email. Same day appointments requiring re-scheduling must be re-scheduled within the same day, otherwise it will be considered a late cancellation.

General Appointment reminders: Appointment reminders are a courtesy only and shall not be relied on as errors may happen between software system and phone carrier. Patients are ultimately responsible for management of treatment schedule. We recommend to keep an updated copy of your schedule and enter your treatment schedule into your personal phone/calendar.

Text Reminders: Courtesy text reminders are delivered 3 days prior to scheduled appointment via Luma Health Software. The patient has the option to confirm appointment or cancel appointment. Any cancellation within 48 hours of scheduled appointment time will be subject to the late cancellation policy.

Email Reminders: Courtesy email reminders may be delivered from ESPT’s front desk email address to provide patients with an overview of upcoming scheduled appointments.

Consecutive Cancellations/No-Shows: When we notice repeated cancellations or missed appointment, we will call you to confirm your next appointment and also ask if you plan to continue care. If you do not respond to our requests, we may close your case and cancel remaining appointments. Any late cancellations or no-show fees incurred will be your responsibility and all balances will need to be paid up-to-date in order to resume care.

Auto Insurance: We do not accept auto insurance – if you have endured an injury from a motor vehicle accident, you have the option to pay out-of-pocket and a detailed receipt of services can be given to you in order to submit for reimbursement by the auto insurance.

Accepted Insurances: We accept major PPO insurances including Aetna, Blue Shield, Blue Cross, United Health Care, Health Net. We do NOT accept Cigna, MediCal (exception MediCal w/ Medicare), HMO plans, Alameda Alliance, Community Health Center Network

Insurance Authorization Policy: Select insurance plans require pre-authorization of physical therapy office visits. This may require you to complete an outcome measures survey and authorization request form which will be submitted on your behalf by ESPT. Elite Sports Physical Therapy will only provide PT services within the approved authorizations. If authorization is in progress or has not been approved, you have the option to continue care out-of-pocket or discontinue treatment.

Medicare: We accept Medicare PPO plans only

Medicare billing and insurance: Patients are able to use Medicare as their primary insurance to cover 80% of their billing claim and use a secondary insurance to cover the remainder 20%. There is a small deductible of $183.

Medicare Therapy Cap Policy: Medicare’s Therapy Cap is $2010.00 for physical therapy and occupational therapy services during the calendar year. If physical therapy services are required beyond the therapy cap for surgical post- rehabilitation – we apply the appropriate billing modifiers to request for approval, however there are no guarantees for Medicare coverage. Any unpaid balances will be placed under the responsibility of the individual.

Maximal Physical Therapy Visit Limit: Elite Sports Physical Therapy will provide physical therapy services within a person’s maximum physical therapy visit limit only. We will not be responsible for requesting additional visits outside of maximum PT visit benefits and we do not perform peer reviews for authorization requests. Patients requesting to receive treatment beyond their insurance’s PT maximum visit benefits for physical therapy will need to continue the remainder of their care out-of-pocket. Receipts can be available upon request for you to submit billing claims to insurance for reimbursement, if available by insurance – please check with your individual insurance.

Traveler’s Insurance: We do not accept Traveler’s Insurance. If you wish to receive PT services at our facility – you will need to pay out-of-pocket.

Worker’s Comp: We accept workers’ comp and require authorization for treatment prior to scheduling initial examination and follow-up appointments. We have a strict attendance policy with workers’ comp and patients with poor attendance or are non-compliant will be discharged from ESPT care. Any no-show fees incurred will be the individual’s responsibility and will have to abide by ESPT’s no-show/late cancellation policy.

Elite Sports Physical Therapy commits itself to legal and ethical billing practices. All billing follows the Rule of 8’s for private parties or the Medicare 8-minute rule. The Rule of 8’s states that one unit can be billed when at least 8 minutes of a 15-minute service is performed for that service.

Telehealth, or clinical video telehealth or telemedicine, involves the use of use of real-time interactive video conferencing with a physical therapist in order to assess, treat and provide care remotely. This requires live two-way audio and video technology. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of your patient identification and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits: No results can be guaranteed or assured

• Improved access to physical therapy care
• Less likely to skip an appointment due to transportation, work, child-care issues, or mild sickness
• Eliminate the need for travel
• Can receive PT treatment from an ESPT provider while you are anywhere within California
• Requires less time in your day – average 25-30 minutes for a telehealth visit
• Improved use of home environment for home exercise program
• More accurate home recommendations for bedroom (sleeping positions), home/work office, bathroom safety, etc.

Possible Risks: These risks include, but may not be limited to:

• In rare cases, the physical therapist may determine that there is inadequate video/audio quality, requiring a face-to-face meeting, or at least a rescheduled video consult;
• Delays in PT evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;

Patient Consent to the Use of Telemedicine

1. I understand that a telehealth visit will not be the same as an in-person physical visit.
2. I understand there are potential risks to this technology including interruptions, unauthorized access, or technical difficulties. I understand that my PT or I can discontinue the visit if it is felt that the videoconferencing connections are inadequate.
3. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth, and that no information obtained in the use of telehealth, which identifies me, will be disclosed to researchers or other entities without my written consent.
4. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
5. I understand that some parts of the examination involving mobility/strength assessments, and special tests may not have the best diagnostic accuracy as an in-person visit.
6. I understand that some parts of treatment may not be as effective as an in-person visit due to no physical contact with provider.
7. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
8. I understand that a physical therapist student may also conduct my telehealth visit and understand that my care will be under direct supervision of a licensed physical therapist
9. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes.
10. I understand that my telehealth visit may be recorded or monitored for quality assurance purposes.
11. I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any time.
12. I understand that ESPT policies regarding scheduling, late cancellations and missed appointments (no-shows) apply to telehealth visits in the same manner as in-office visits.
13. I understand that financial policies and payment procedures are the same whether service is provided in person or through telehealth including payment procedures for co-pays, billing of procedures/interventions performed during visit.

You, the patient, will be receiving direct physical therapy treatment services from an individual who is a physical therapist (PT) licensed by the Physical Therapy
Board of California.

Under California law, you may continue to receive direct physical therapy treatment services for a period of up to 45 calendar days or 12 visits, whichever occurs first, after which time an updated prescription is needed.

A physical therapist may continue providing you with physical therapy treatment services only after receiving, from a person holding a physician and surgeon’s certificate, issued by the Medical Board of California or by the Osteopathic Medical Board of
California, or from a person holding a certificate to practice podiatric medicine from the California Board of Podiatric Medicine and acting within his or her scope of practice, a dated signature on the physical therapist’s
plan of care indicating approval of the physical therapist’s plan of care and that an in-person patient examination and evaluation was conducted by the physician and surgeon or podiatrist. With your written authorization, your physical therapist shall notify your physician and surgeon, if any, that he/she is treating you.

I hereby authorize Elite Sports Physical Therapy, through its appropriate personnel, to perform or have performed upon me, or the above named patient, appropriate assessment and treatment procedures relating to my condition.

I further authorize Elite Sports Physical Therapy to release to appropriate agencies, any information acquired in the course of my or the above named patient’s examination and treatment.

I acknowledge that Elite Sports Physical Therapy reserves the right to refuse service to anyone choosing not to abide by facility policies or deemed to be disruptive to other patients or staff members. Elite Sports Physical Therapy does not discriminate and will not deny service to individuals based on any other reason.

Elite Sports Physical Therapy maintains records of the healthcare services we provide to you. You may ask for a copy of that record at any time. Your medical records are confidential and we will not disclose your record to others unless you direct us to or the law authorizes or compels us to do so.

Our Notice of Privacy Practices describes in more detail how your protected health information may be used and disclosed and how you can access your information.

By electing to participate in physical therapy from ESPT, you are accepting financial responsibility for the services that we will provide. This responsibility obligates you to ensure payment in full of your fees. As part of our program, we would like to take this opportunity to let you know how our billing and insurance reimbursement services function. At ESPT, we will bill any insurance company as a courtesy to you, but it is your responsibility to contact your provider, if you need clarification on your benefits for outpatient physical therapy. Most insurance providers require a written prescription from a medical provider (physician, chiropractor, osteopath) in order for physical therapy services to be reimbursed. These insurance plans also place a “cap” on outpatient rehabilitative services. This means that they will only pay a set amount per visit or a set number of visits within a calendar year. Any balance above and beyond the insurance coverage, will be your responsibility. Deductibles and copayments/coinsurance may also apply depending on your insurance. Copayments are due at the time of service.

Authorization and Content: Except as outlined below, we will not use or disclose your PHI for any purpose other than treatment, payment, or health care operations unless you have signed a form authorizing the use or disclosures. You have the right to revoke that authorization in writing unless we have taken any action in reliance on the authorization

Uses and disclosures for Treatment: With your agreement, we will make uses and disclosures of your PHI as necessary for treatment. Our staff that is involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to your determine your course of treatment that may include procedures, tests, referral to appropriate providers, medical history, etc. We may disclose your PHI to another on of your treatment providers in the community, unless the provider is not currently providing treatment to you and you direct us in writing not make the disclosure.

Uses and Disclosures to health Care Organizations: With your agreement, we will use and disclose your personal health information as necessary, and as permitted by law, for our health care operations, which may include clinical improvement, professional peer review, business management, accreditation, and licensing, etc. For instance, we may use and disclose your PHI for purposes of improving the clinical treatment and patientcare of ESPT.

Individuals Involved in Your Care: Unless you notify us in writing of your desire to restrict disclosure, we may from time to time provide relevant PHI to designated family, friends, and others who are involved in your care or in payment of your care in order to facilitate that person’s involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest; we may share limited PHI with involved individuals without your approval.

Business Associates: Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, outcome data collection, legal services, etc. At times it may be necessary for us to provide your PHI to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information.

Train Staff and Students: We may use and disclose your information to teach and train staff and students. One example of this is when we review your PHI with physical therapy students/interns.

Other Uses and Disclosures: We are permitted and/or required by law to make certain other uses and disclosures of your PHI without your consent or authorization for the following:

• Any purpose required by law,
• Public health activities, such as required reporting of disease, injury, birth, and death, or required public health investigations,
• If we suspect child abuse or neglect; if we believe you to be a victim of abuse, neglect, or domestic violence
• To the Food and Drug Administration (FDA) to report adverse events, product defects, or to participate in product recalls,
• To your employer when we have provided health care to you at the request of your employer,
• To a government oversight agency conducting audits, investigations, or civil criminal proceedings,
• Court or administrative ordered subpoena or discovery request,
• To law enforcement officials as required by law to report wounds and injuries and crimes,
• To coroners and/or funeral directors constituent with law,
• If you are a member of the military, we may also release your PHI for national security or intelligence activities, and
• To workers’ compensation agencies for workers’ compensation benefit determination.

Rights that you have regarding your Personal Health Information (PHI)

• Access to Your PHI: You have the right to copy and/or inspect much of the PHI that we retain on your behalf. All requests for access must be made in writing and signed by you or your legal representative. You may obtain a “Patient Access To Personal Health Information Form” form the front office person.
• Amendments to Your PHI: You have the right to request in writing that personal health information that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests, must in writing, signed by you or your legal representative, and must state the reasons for the amendment/correction request. If an amendment or correction request is made, we may notify others who work with us if we believe that such notification is necessary.
• Accounting for Disclosures of Your PHI: You have the right to receive an accounting of certain disclosures made by us of your personal health information. Requests must be made in writing and signed by you or your legal representative. The first accounting in any 12-month period is free; you will be charged a fee for each subsequent accounting you request within the same 12-month period. You will be notified as the fee at the time of your request.
• Restrictions on Use and Disclosure of Your PHI: You have the right to request restrictions on uses and disclosures of your PHI for treatment, payment, or health care operations. We are not required to agree to your restriction request, but will attempt to accommodate reasonable request when appropriate. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction by sending such termination notice to Elite Sports Physical Therapy.
• Workers’ Compensation: Medical information generated for services provided to Workers’ Compensation patients is not covered by HIPAA. As such, Worker’s Compensation patients do not have the right to restrict, amend, or request an accounting of their PHI generated for purposes of Worker’s Compensation
• Complaints: If you are concerned that your privacy rights have been violated or you disagree with a decision we made about access to your records, you may file a complaint in writing with us at Elite Sports Physical Therapy. You may also file a complaint with the Secretary of the U.S. Department of Health and human Services in Washington D.C. in writing within 180 days of violation of your rights. There will be no retaliation for filing a complaint.

Elite Sports Physical Therapy may record video or photograph patients to use for training or marketing purposes. If video or photo is taken – we will only do so with the consent of the patient and with a signed testimonial release form. The signed content/testimonial release authorizes Elite Sports Physical Therapy that the use, reproduction, and publishing of photographs, testimonials, statements, and/or video content (“Content”) that may contain my image, likeness, and/or voice. I agree and understand I shall neither be compensated for the Content nor receive attribution for the Content.