I am aware that Change in Motion, through its employees or agents, will provide occupational therapy evaluation and treatment to me in my home and in outdoor spaces. I understand that these services may carry the following risks: physical pain and discomfort, physical injury and stress, falls and property damage. I understand these risks are not exhaustive and that there may be other, more remote risks and consequences. I have been advised that a more detailed explanation will be given to me if I so desire, and I do not want further explanation. I have received no guarantees from anyone of the results that may be obtained. I will fully participate in Change in Motion occupational therapy and disclose any medical reason why my participation might be limited. I hereby consent to receiving these services.
Change in Motion may document medical and other information related to my treatment in electronic and other forms and that such information will be used in the course of my treatment, for payment purposes and to support those involved in my care. Change in Motion will not divulge any confidential information (information not generally known) without permission, unless permitted or required by law.
I authorize Change in Motion to use and disclose my health information to any insurance company, Medicare, or other entity as necessary for payment for the services provided to me by Change in Motion. I have provided Change in Motion with all current and correct medical insurance information. I hereby assign to Change in Motion all my rights and claims for reimbursement under my health insurance policy. I authorize and direct the insurance company, Medicare, or other entity to pay all benefits payable to Change in Motion.
I agree to receive services through phone call or video call after the initial evaluation. I acknowledge and agree that phone and video calls may come with inherent risks of privacy security, and that while all reasonable measures are taken to secure my personal health information, no technology interface is fully secure.
In consideration of being allowed to receive the services described above, I do hereby waive, release and forever discharge Change in Motion LLC, and its affiliates, officers, employees, agents, representatives and all others acting on its behalf, their successors and assigns (the “Released Parties”), from any and all claims or causes of action (known or unknown) for any and all injury, illness, damage or loss that may occur to me or my property as a result of my receipt of services, including, but not limited to, my use of any recommended services or devices, whether or not said injury, illness, damage, or loss is caused in whole or in part by the negligence of any of the Released Parties. I intend for the foregoing waiver, release and discharge to be binding upon my heirs, executors, administrators, successors and assigns.
This consent and authorization given to Change in Motion as set forth above will remain in full force and effect per episode of care (initial assessment to discharge) until terminated in writing by me or my authorized representative. This termination will not be effective until Change in Motion receives this request in writing.
I understand that, under the Health Insurance Portability & Accountability Act (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations.
I understand that the Change In Motion Notice of Privacy Practices contains a more complete description of these uses and disclosures of my health information. I understand that the Notice of Privacy Practices is available online at www.ChangeInMotionPA.com, and that printed copies are available upon request. I have been given the right to review such notice of privacy practices prior to signing this consent. I understand that this organization that the right to change its notice of privacy practices from time to time and that I may contact this organization to obtain a current copy of the notice of privacy practices. I understand that I may request in writing that Change In Motion restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand Change In Motion is not required to agree to my requested restrictions, but if it does agree, then it is bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that Change In Motion has taken action relying on this consent.
By my signature below, I hereby certify that I have read, understand, and fully agree to each of the statements in this document; that all of my questions have been answered to my satisfaction; and that I sign below freely and voluntarily.
