Patient Personal Information
Emergency Contact Info
Referring Provider Info (if applicable)
Please Provide Us with Your Medical History
Your Information. Your Rights. Our Responsibilities.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Your Rights
Get a copy of your paper or electronic medical record
Correct your paper or electronic medical record
Request confidential communication
Ask us to limit the information we share
Get a list of those with whom we’ve shared your information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and share information as we:
Tell family and friends about your condition
Provide disaster relief
Include you in a hospital directory
Provide mental health care
Market our services and sell your information
Raise funds
Our Uses and Disclosures
We may use and share your information as we:
Treat you
Run our organization
Bill for your services
Help with public health and safety issues
Do research
Comply with the law
Respond to organ and tissue donation requests
Work with a medical examiner or funeral director
Address workers’ compensation, law enforcement, and other government requests
Respond to lawsuits and legal actions
Your Health Information
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting us using the information on our website or through the privacy official below.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
Marketing purposes
Sale of your information
Most sharing of psychotherapy notes
In the case of fundraising:
We may contact you for fundraising efforts, but you can tell us not to contact you again.
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
We can share health information about you for certain situations such as:
Preventing disease / Helping with product recalls / Reporting adverse reactions to medications / Reporting suspected abuse, neglect, or domestic violence / Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research.
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
We can share health information about you with organ procurement organizations.
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
We can use or share health information about you:
For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.
Effective date: January 2025
Privacy Official: Courtney Perkins | [email protected] | Phone #: 540-208-1785
Email and Texting Messaging Agreement
Neuro Outlook, LLC values communication between therapists and clients.
We appreciate having the ability to communicate with you by email or text messaging as this is often the most convenient method for both therapists and clients. However, when you consent to communicating with us by email, text or phone, you are agreeing to accept the risk that your protected health information may be intercepted by persons not authorized to receive such information. Since we do not control the email and phone systems you use, we are not responsible for any privacy or security breaches that may occur through voicemail, email or text communications that you have consented to. It is possible that email and text messaging security can be compromised, and it is beyond the control of Neuro Outlook, LLC to maintain the security of communications beyond using routine internet safety practices and safeguards. You may opt out of text messaging or email communications at any time by communicating with us about your preferences. By opting out of texts or emails you will be opting out of our appointment reminder system as well.
Photo / Video / Testimonial Release Form
Neuro Outlook, LLC occasionally gathers photos and videos of the treatment process with clients.
Neuro Outlook, LLC is seeking your approval for the following reasons:
To use photographs/video footage taken of clients and their home's for use on associated websites, emails, fliers and any promotional ads.
To utilize written testimonials, quotes, and other written material for use on associated websites, emails, fliers and any promotional ads.
By agreeing below you hereby waive any right to inspect or approve the finished photographs/video footages or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to you or unknown, and you waive any right to royalties or other compensation arising from or related to the use of the photograph/video footage and written material.
You also hereby agree to release, defend, and hold harmless Neuro Outlook, LLC and its affiliates from and against any claims, damages or liability arising from or related to the use of the photographs/video footage, written statements, testimonials, quotes, including but not limited to any misuse, distortion, blurring, alteration, or use in composite form, either intentionally of the finished product, its publication or distribution.
You may notify Neuro Outlook, LLC verbally or in writing if you choose to rescind your permission as detailed herein.
By signing below you agree to the following statement: "I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release."
Release of Information
I, the above-named patient (or the parent or legal guardian), authorize Neuro Rehab Collaborative, LLC partners to provide my medical records containing the health information described within, to the recipients that I have identified below. Additionally, I grant permission for my treating healthcare professionals to discuss my care with other members of the Neuro Rehab Collaborative team including:
Valley Physical Medicine & Rehabilitation, LLC (Valley PM&R)
Neuro Outlook, LLC (Physical Therapy)
Function First OT, LLC (Occupational Therapy)
Refusal to sign/right to revoke:
I understand that signing this form is voluntary, and if I change my mind, I understand that I can revoke this Authorization by providing a written notice of revocation to the Provider at the address provided to me.
Notice of Privacy Practices
I acknowledge receipt of the Notice of Privacy Practices from Neuro Outlook, LLC. I understand that the Notice of Privacy Practices provides information about how Neuro Outlook, LLC may use and disclose my protected health information. I have reviewed it and understand that the Notice of Privacy Practices is subject to change. If the Notice is changed, I may request a revised copy.
Financial Responsibilities
Assignment of Insurance Benefits: I hereby authorize that the payment of authorized benefits be made directly to Neuro Outlook, LLC of any services that are reimbursable by Medicare and or other insurances if applicable.
In-Network Insurances: If we are in-network with your health plan, we will submit the claims to your health plan on your behalf and your health plan will send payment directly to us. I understand that if my health plan denies payment, in whole or in part, I am responsible for paying any and all unpaid amounts upon receipt of invoice. I understand that if any insurance payments are sent directly to me that I will promptly forward the funds and explanation of benefits/payment to Neuro Outlook, LLC.
Out-Of-Network Insurances: If your insurance allows out-of network claims, we will bill your health plan for our services directly and await payment from your health plan. I agree if my health plan does not honor the assignment and if payments are sent directly to me that I will promptly forward the payment. I understand that if my health plan denies payment of claims, in whole or in part, that I am responsible for paying any and all unpaid amounts upon receipt of invoice to Neuro Outlook, LLC.
Medicare: I hereby certify that the information given by me in applying for payment under title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any such information needed for this or a related Medicare Claim. I request
that the payment of authorized benefits be made on my behalf. I understand that I am responsible for any health insurance deductibles and co-insurance. I understand that I cannot receive Medicare Part B services in the home if I am currently on Home Health under Medicare Part A and or on Hospice Care (unless diagnosis is unrelated to Hospice diagnosis). I
understand that services must be skilled and medically necessary to be covered by Medicare Part B. I understand Medicare will pay for 80% of the allowed amount, and I am responsible for the remaining 20% if I do not have a secondary insurance.
Medicare Advantage Plans. We are out of network with all Medicare Advantage Plans. If you have out-of-network benefits, we will provide you with a copy of your bill that you can, at your discretion, submit to your Medicare Advantage Plan for reimbursement for the services your health plan covers. If your insurance allows out-of network claims, we will bill your health plan for our services directly and await payment from your health plan. I agree if my health plan does not honor the assignment and if payments are sent directly to me that I will promptly forward the payment. We will require you to pay an estimated payment at the time of each visit or once we receive your EOB back from your insurance. When you receive your Explanation of Benefits (“EOB”) from your Medicare Advantage Plan that shows how much we were allowed to charge, please provide us a copy so we can reconcile your account.
TriCare Policy. We are out-of-network with TriCare. Therefore, you will be responsible for paying for all services rendered by Neuro Outlook, LLC.
Worker’s Compensation: If you have a work related injury and have notified your employer and filed an injury report, we can submit claims to workman's compensation after receiving authorization. I understand that it is my responsibility for payment in the event of a dispute or denial.
Private Payment Policy. We offer a discounted private payment rate when patients pay within 3 business days of the day of service in exchange for the prompt payment and the reduction in administrative work/time since we do not have to file claims or obtain pre-authorization. This prompt payment discount is offered to clients who do not have insurance or who choose not to use their health plan benefits. If we are in-network with your health plan, our prompt payment rate may be less than the in-network rate that we have negotiated with your health plan. If you choose to take advantage of our discounted private payment policy, you understand that we will not submit a claim to your health plan and you agree that you will not submit our claims or statements to your health plan in an attempt to get reimbursed for our services. If you choose to pay privately initially and later want to switch to using your health plan, you understand that the fees for our services may be higher and you will no longer be entitled to our discounted private pay price. Your ability to switch to using your health plan benefits may also be limited by your health plan’s requirements for pre-authorization or other policy limitations.
Private Payment Guarantee of Account: I understand that the services being provided will not be billed to insurance. That I will not submit the claims to my insurance, and that payment is due to Neuro Outlook, LLC day of service for any private pay services.
Private Payment Good Faith Estimate: I understand and acknowledge that I will be provided with a good faith estimate for any private pay services if requested.
Cancellation/No Show Policy: I understand that I will be charged a missed visit fee of $50 if I cancel less than 24 hours from my visit. This amount is my responsibility. I understand if I cancel more than 2x I will be placed on a same day scheduling list.
Estimate of Insurance Payment/Expense: It is your responsibility to know and understand your insurance benefits. Insurance verification is provided as a courtesy and should be considered an approximation rather than a guaranteed accuracy. Based on the insurance information provided to Neuro Outlook, LLC, the following represents our best estimate of payment and expenses.
Insurance Verification/Authorizations: I understand that it is my responsibility to understand my insurance coverage and what I am responsible for (deductibles, coinsurance, copay) and if I have any requirements for authorizations and visit limits.
Appeals Policy: You understand that you are responsible for filing all appeals of adverse benefit determinations. If you need assistance filing an appeal with your health plan, contact the consumer assistance agency on your denial letter.
Late Payment Penalty: Unless prohibited by applicable law, a late payment penalty in the amount of 2.7% per month (33.33% per year) may be added to your bill for any and all claims that are not paid within thirty (30) days of the invoice or statement date. You agree to be personally responsible for paying this late payment penalty unless the responsible Payor is required to pay such interest under federal, state or other applicable laws.
Collection Policy: You understand that we are not required to obtain your written authorization to disclose protected health information to a collection agency or court of law that may be necessary to collect payment for services rendered. Should collection proceedings or other legal action become necessary to collect an overdue account, you will be responsible for paying the collection costs plus court costs and filing fees incurred by the practice. If my account is past due, I must have an approved payment plan in place. Otherwise, I understand that no further visits will occur until my account is paid in full or a payment plan is established.
Insufficient Funds: I understand that if I make a payment by a check that has insufficient funds, I will be charged a returned check fee of $30.
Explanation of Billing: I understand that Neuro Outlook, LLC has an explanation of billing on their website and upon request will provide a copy via email.
Guarantee of Account: I hereby guarantee payment for any and all services rendered to me which are not covered or allowable by Insurance, together with collection costs, including reasonable attorney fees. I also understand that all bills are due and payable upon invoice. I understand that the client responsibility portion of my bill shall be due and payable at time of invoice. I understand that I am personally responsible for full payment of all charges including insurance denials, deductibles, copayment and coinsurance fees. I understand that I will be provided with an invoice for services not covered.
Invoices: I understand that invoices will be sent to me via email and text messaging. Paper statements can be mailed out per individual request. If another person is responsible for payment please notify us in person with their name, phone/email address that statements should be sent to.
Service Termination Policy: If we determine at any time that conditions in your home create a potentially unsafe environment for our providers, we may, at our sole discretion, terminate our services with you. If we do so, we will make reasonable efforts to refer you to the services you need to resolve the issue that is causing a potentially unsafe environment. If you have prepaid for any services, we will refund any monies paid for services not yet received as of the date or our termination.
By signing this document, I acknowledge that I have read it or have had it read to me and have had an opportunity to discuss it with my caregiver. I fully understand the document and consent to its terms: Release of Information, Consent for Caregiver Training, Notice of Privacy Practices, and Email/Text Messaging agreement.
Informed Consent Form
You have consulted with Neuro Outlook, LLC and have decided to receive therapy services. It is important that you, the client, read this consent form carefully and obtain answers to any questions that you may have.
I hereby consent to a physical therapy, occupational therapy, and/or speech language pathology examination and subsequent treatment as recommended by the examining physical therapist, occupational therapist, and/or speech language pathologist.
Examination. I understand the examination includes providing a medical, social, and physical activity history and reporting of my symptoms and complaints. I agree to allow the physical therapist, occupational therapist, and/or speech-language pathologist to perform all tests and measures required to identify my physical therapy, occupational therapy, and/or speech therapy diagnosis, problems, and prognosis. I understand that some tests and measures may require the physical therapist, occupational therapist, and/or speech-language pathologist to perform a visual inspection of exposed body areas or palpate body parts that are sensitive or painful. I understand that the speech-language pathology examination may include assessment of speech, language, cognition, voice, and swallowing, and may involve speaking, reading, memory tasks, or supervised eating and drinking. I understand that there are some risks in participating in a physical, occupational, or speech therapy examination, including but not limited to soreness, increased or new pain, fatigue, frustration, aggravation of symptoms, or a new injury. I understand that if I am uncomfortable at any time during the examination, I can let the therapist know and may refuse to continue the examination at my choice. If I refuse to participate in any part of the examination, I understand that the physical therapist, occupational therapist, and/or speech-language pathologist may not be able to provide an accurate diagnosis or prognosis or develop the most appropriate treatment plan.
Treatment. I acknowledge that my physical therapist, occupational therapist, and/or speech-language pathologist (hereinafter “PT,” “OT,” or “SLP”) has informed me of my diagnosis, prognosis, and the potential risks and benefits of all recommended interventions in my proposed plan of care, and I have been given the opportunity to have all my questions answered. I hereby agree to participate in and consent to receive the physical, occupational, and/or speech therapy interventions recommended by my PT, OT, and/or SLP as outlined in my treatment plan. I understand that individual responses to therapy interventions vary, and that treatment may occasionally result in increased pain, fatigue, frustration, aggravation of existing symptoms, or a new injury. I agree to inform my PT, OT, or SLP of any changes in my symptoms, function, or tolerance so my treatment plan can be adjusted accordingly. I understand that I may decline any intervention at any time by informing my PT, OT, or SLP of my concerns, and that refusal of essential interventions may result in termination of treatment if no appropriate alternatives exist. I also understand that while we have set rehabilitation goals, no guarantees have been made regarding specific outcomes from therapy.
You have the right to inquire as to the form of treatment based upon your history, diagnosis, and symptoms.
Consent to Record & Use of AI Scribe for Documentation. In order to enhance the quality and efficiency of medical documentation during my care, I understand that Neuro Outlook LLC uses an AI-powered documentation tool, HippoScribe, which may record audio during patient engagements.
Data Security & Confidentiality: The information collected through HippoScribe is protected under HIPAA guidelines. Audio recordings and any patient information processed through HippoScribe are encrypted and securely stored. My health information will not be used to train or improve any AI model.
Purpose of Use: The use of HippoScribe is intended solely to assist with documentation and accuracy.
Potential Risks: While efforts are made to ensure data security, there is a minimal risk of transcription errors or potential data breaches.
By signing this form, I give my consent to the use of HippoScribe for documentation during my treatment. I understand that I can withdraw this consent at any time, without affecting the quality of my care.
You have the right to decline treatment at any time or during your treatment sessions.
Your therapist will answer questions you may have regarding a given course of treatment, type of exercise or treatment method, associated risks, and possible alternatives.
This consent form is based upon your informed decision to participate in the proposed treatment plan for therapy services. Neuro Outlook, LLC has discussed with me in words that I can understand, my diagnosis, conditions, reasons for and benefits of the plan of care, the reasonable likelihood of success, the possible material risks of not following the plan of care, the possible risks associated with the plan of care, and possible alternatives and risks associated with those alternatives. Neuro Outlook, LLC and I have discussed my goals of recovery and potential problems that might arise during treatment. I have decided not to participate in alternative treatments at this time. I understand there are risks associated with therapy as described above. I am giving this consent with the understanding that any treatment or services involve some risks and hazards, and that no guarantees have been made to me.
I hereby consent to such treatment procedures and patient care which, in the judgment of my therapist and/or physician, may be considered necessary or advisable while I am a patient of Neuro Outlook, LLC
I acknowledge that services may be provided to me by another therapist other than identified on this form or that have been assigned to me.
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Neuro Outlook
All rights reserved.
