Intake Forms

HIPAA Notice of Privacy Practices
This notice describes how your medical information may be used and disclosed and how you can get access to this information. Please review it carefully.ADVANCED PHYSICAL MEDICINE AND REHABILITATION, LLC and its subsidiaries is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

Disclosure of your Health Care Information

TreatmentWe may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. “It is our policy to provide a substitute health care provider, authorized by Advanced Physical Medicine and Rehabilitation, LLC and its subsidiaries, to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary health care provider’s absence due to vacation, sickness, or other emergency situation.”PaymentWe may disclose your health information to your insurance provider for the purpose of payment or health care operations.If payment is not made as arranged, our office may utilize an outside collection agency, credit reporting agency or other means of collecting outstanding debt. The designated collection agency or authority may review your file containing protected health care information at your expense.Workers’ CompensationIf applicable, we may disclose your health information as necessary to comply with state Workers’ Compensation Laws.EmergenciesWe may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care, about your medical condition or in the event of an emergency or of your death.Public HealthAs required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.Judicial and Administrative ProceedingsWe may disclose your health information in the course of any administrative or judicial proceeding.Law EnforcementWe may disclose your health information to a law enforcement official for purposes such as identifying of locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena and other law enforcement purposes.Deceased PersonsWe may disclose your health information to coroners or medical examiners.Organ Donation & ResearchThough highly unlikely or probable we must inform you that there may a need to release your health information to organizations involved in procuring, banking or transplanting organs and tissues, or to researchers conducting research that has been approved by an Institutional Review Board.Public SafetyIt may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.Specialized Government AgenciesWe may disclose your health information for military, national security, prisoner and government benefits purposes.Marketing & Other CommunicationWe may contact you for marketing or fundraising purposes but will not disclose any health care information without your written consent.“As a courtesy to our patients, it is our policy to call your home on the evening prior to your schedule appointment to remind you of your appointment time. If you are not at home, we leave a reminder message on your answering machine or with the person answering the phone. No protected health information will be disclosed during this call other than the date and time of your scheduled appointment and a request to call our office if you need to cancel or reschedule your appointment.”Changes to this Notice of Privacy PracticesThis office reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, we are required by law to comply with this Notice.ComplaintsComplaints about your privacy rights, or how Advanced Physical Medicine and Rehabilitation, LLC and its subsidiaries has handled your health information should be directed to Dr. Daniel Reizis by calling this office at 732-894-9200. If Dr. Daniel Reizis is not available, you may make an appointment to discuss the matter in person or by telephone.If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:DHHS, Office of Civil Rights 200 Independence Avenue, S.W. Room 509F HHH Building Washington, DC 20201Your Health Information Rights– You have the right to request restrictions on certain uses and disclosures of your health information. If services are paid in full by cash you may restrict that information to any insurer for purposes other than for treatment.– You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.– You have a right to request that we amend your protected health information. Please be advised, however, that we may not be required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.– You have a right to receive an accounting of disclosures of your protected health information made by Advanced Physical Medicine and Rehabilitation, LLC and its subsidiaries.– You have a right to a paper copy of this Notice of Privacy Practices at any time upon requestFOR ADDITIONAL INFORMATION ABOUT YOUR PRIVACY, PLEASE VISIT: http://www.hhs.gov/ocr/privacy/
Assignment of Benefits Form
Assignment of BenefitsI hereby assign all medical and surgical equipment benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance and any other health/medical plan, to issue payment check(s) directly to Advanced Physical Medicine and Rehabilitation, LLC and its subsidiaries for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.Authorization to Release InformationI hereby appoint and authorize Advanced Physical Medicine and Rehabilitation, LLC and its subsidiaries, as my Designated Representative to:
  1. Release any information necessary to insurance carriers regarding my illness and treatments.
  2. Process insurance claims generated in the course of examination and/or treatment.
  3. Submit written appeals to my insurance carrier on my behalf, and give permission for my insurance carrier to fully communicate with my Designated Representative, to obtain official information regarding any appeals performed, written and/or submitted, and/or act on all future matters related to the appeal process on my behalf.
  4. Allow a photocopy of my signature to be used to process insurance claims and will remain in effect until revoked by me in writing.
I have requested medical services from Advanced Physical Medicine and Rehabilitation, LLC and its subsidiaries on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized. A photocopy of this assignment is to be considered as valid as the original.Payment PolicyIf you receive any payments from your insurance company for services rendered at our office, the payment must be brought into this office within one week of receipt and endorsed over to this office. If you fail to provide us with any and all payments made from your insurance company within 30 days of the check date you will be assessed a 5% late fee along with any potential legal fees.
Timeliness Policy
We value your time and don’t want to keep you waiting. Occasionally we are delayed by an unexpected event with another patient but be assured that the quality of your time will not suffer. If you arrive late, your treatment will end on its scheduled time in order not to keep the next person waiting.No Shows/CancellationsIt is important to keep any appointments you schedule or contact us if you cannot. This way we can schedule others who wish to be treated. Kindly give 24 hours notice if you have to cancel or reschedule your appointment. More than 1 cancellation or no show during the course of your treatment may influence our ability to schedule future appointments. If you have a scheduled appointment and fail to contact our office to cancel or reschedule prior to your appointment time a $100.00 charge will be assessed to your account, unless amended at the discretion of Advanced Physical Medicine and Rehabilitation, LLC and its subsidiaries. This charge will NOT be assessed to your insurance company and is YOUR responsibility.
Informed Consent
I, the undersigned, acknowledge ADVANCED PHYSICAL MEDICINE AND REHABILITATION, LLC and its subsidiaries the inherent risks involved when using any type of fitness equipment at and in all other physical therapy, acupuncture or any other medical treatments relating therein. Accordingly, as consideration in exchange for being allowed to participate in any activities at ADVANCED PHYSICAL MEDICINE AND REHABILITATION, LLC and its subsidiaries, I hereby agree to and initial the following:
  1. I acknowledge that I am participating in physical therapy, acupuncture or any other medical treatments offered by ADVANCED PHYSICAL MEDICINE AND REHABILITATION, LLC and its subsidiaries during which I will receive instruction and information about health and fitness. I recognize that any of these treatments require physical exertion, which may be strenuous and may cause physical injury, permanent disability and even death, and I am fully aware of the risks and hazards involved.
  2. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any treatment programs. I represent and warrant that I am physically fit and I have no medical condition which would prevent my full participation in a treatment program.
  3. In consideration of being permitted to participate in a treatment program, I agree to assume full responsibility for any risks, injuries, permanent disability, death, or damages, known or unknown, which I might incur as a result of participating in the program. If, however, I observe any unusual significant hazard during my participation, I will remove myself from participation and bring such hazard to the attention of management.
  4. In further consideration of being permitted to participate in a treatment program, I knowingly, voluntarily, and expressly waive any claim I may have against ADVANCED PHYSICAL MEDICINE AND REHABILITATION, LLC and its subsidiaries, its members, managers, affiliates, officers, directors, employees, agents or any therapist (collectively “Releasees”), for injury or damages that I may sustain as a result of participating in the program. I also agree to indemnify Releasees from any and all third-party claims caused or resulting in whole or in part by my actions.
  5. I, my heirs and legal representatives forever release, waive, discharge and covenant not to sue any of the Releasees, for injury or death caused by their negligence or other acts.
  6. I consent to emergency medical care and transportation in order to obtain treatment in the event of injury to me as ADVANCED PHYSICAL MEDICINE AND REHABILITATION, LLC and its subsidiaries may deem appropriate. The releases contained herein extend to any liability arising out of or in any way connected with the medical treatment and transportation provided in the event of any emergency.
  7. I expressly agree that the terms of release and indemnity contained herein are intended to be as broad and inclusive as is permitted by the laws of the State of New Jersey. Any provision or portion of this Agreement of Release and Waiver of Liability found to be invalid by the courts having jurisdiction shall be invalid only with respect to such provision or portion hereof. The offending provision or portion shall be construed to the maximum extent possible to confer upon the parties the benefits intended thereby. Said provision or portion hereof, as well as the remaining provisions or portion hereof, shall be construed and enforced to the same effect as if such offending provision or portion thereof had not be contained herein.
I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. I understand that by signing this Agreement I have given up substantial rights.
Transportation Policy
I have been offered transportation services by Advanced Medical Transport, LLC (“AMT”), and by accepting these services I hereby voluntarily release, hold harmless, and discharge Advanced Physical Medicine and Rehabilitation, LLC and its subsidiaries from any and all claims or causes of action for personal injury, property damage, or negligence occurring to me and arising as a result of my use of transportation services provided by AMT and I agree that under no circumstances will I present any claim for personal injury, property damage, or negligence against Advanced Physical Medicine and Rehabilitation, LLC and its subsidiaries, as a result of the negligence and/or gross negligence of AMT.

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