NOTICES OF POLICIES AND PATIENT INFORMTION
PRACTICES: MEDICARE
This notice describes our financial policy, how medical information about you may
be used or disclosed, and how you may receive access to your medical information.
Please review the following information and sign the attached form.
FINANCIAL POLICY:
We will file all claims directly to your insurance carrier. Once your insurance has
processed your claims, you will be billed and required to pay for all co-pay, coinsurance and/or any other amounts not paid by your insurance carrier, We accept
cash, personal checks, Visa or Mastercard.
MEDICARE:
We do accept Medicare assignment. Please be aware that Medicare covers 80% of
the charges for treatment. The patient is responsible for the remaining 20% of the
charges billed. The patient is also responsible for the annual $135. 00 Medicare
deductible if applied to physical therapy charges. As a courtesy, we will bill the
patient’s Medicare supplemental policy. After both Medicare and any
supplemental insurance company have been billed, any remaining balance is the
patient’s responsibility to pay.
LATE FEE:
Any outstanding charges due at the conclusion of treatment will be billed to the
patient. After 21 days and for every billing thereafter a $5.00 rebilling fee will be
added to the unpaid balance. After 60 days the account will be sent to an outside
collection agency. The fee for the collection service is $25.00 and will be charges
to the patient account. If you have any questions regarding billing, you may contact
Katie Vail at 708-499-4497.
Southwest Physical Therapy & Rehabilitation, Ltd’s Legal Duty
Southwest Physical Therapy is required by law to protect the privacy of you information practices that
are described within.
Informed Consent:As a client of Southwest Physical Therapy & Rehabilitation, Ltd. (Southwest) I understand that referral
to this clinic may be based upon a combination of criteria including but not limited to my specific diagnosis, insurance
carrier, location, credentials, personal reference or personal choice.
I understand that the course of treatment at Southwest is determined by a combination of factors including but not limited
to my specific diagnosis, age, work demands/environment, medical history, athletic involvement and personal physical
needs. I accept the program of treatment will be determined as a joint effort by my referring physician and by the result of
the evaluation which is performed by the physical therapist. I expect treatment will be fully explained to me as well as the
pertinence of this treatment to the specific need(s) which I may have at the time of the evaluation. I additionally understand
that my questioning any treatments while under the care of Southwest by no means challenges the abilities or
qualifications of the therapist and does not lessen my commitment to my full cooperation of the program.
I understand that in the course of my treatment at Southwest, I have the right to refuse, at any time, a treatment or
treatments which I feel may not suit my needs or personal preference and that this right will supersede the
recommendation of my physician, primary therapist, or insurance carrier.
Uses and Disclosure of Information:Southwest Physical Therapy & Rehabilitation, Ltd. uses your personal health
information primarily for treatment, obtaining payment, conducting internal administrative activities and evaluating the
quality of care that we provide, For example, Southwest may use your personal health information to contact you to provide
appointment reminders or information about treatment alternatives or other health related benefits. Southwest may also
use or disclose your personal health information without prior authorization for public health purposes, for auditing
purposes, for research studies or for emergencies. We also provide info when required by law.
In any other Situation, Southwest’s policy is obtaining your written authorization before disclosing you personal health
information. If you provide us with written authorization to release your information for any other reason you may later
revoke that authorization to stop future disclosures at any time.
Southwest may change its policy at any time. When changes are made a new notice of Information Practices will be
posted in the waiting room and patient exam areas and will be provided to you on your next visit. You may also request an
updated copy of our Notice of Information Practices at any time.
Patient’s individual Right:You have the right to review or obtain a copy of your personal health information at any time.
You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the
right to request a list of instances where we have disclosed your personal health information for reasons other than
treatment, payment or other related administrative purposes.
You may also request in writing that we not disclose your personal health information for treatment, payments and
administrative purposes except when specifically authorized by you, when required by law or in an emergency. Southwest
will consider all such requests on a case by case basis, but the practice is not legally required to accept them.
Concerns and Complaints:If you are concerned that Southwest Physical Therapy and Rehabilitation, Ltd. May have
violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your
personal health information, please contact our practice manager at the address listed below. You may also send a written
complaint to the US Department of Health and Human Services. For further information on the Southwest Physical
Therapy and Rehabilitation, Ltd’s health information practices or if you have a complaint please contact Katie Vail or
George Cachares at the Oak Lawn office located at 9735 Southwest Highway, Oak Lawn, IL 60453. Telephone: 708-4994497 Fax: 708-499-4597.
Policies and Patient Information Consent Form
I have read and fully understand Southwest Physical Therapy & Rehabilitation, Ltd.’s Notice of
Policies and Patient Information Practices. I understand that I am responsible for payment of
services provided by Southwest Physical Therapy & Rehabilitation, Ltd. I understand that
Southwest Physical Therapy & Rehabilitation, Ltd. may use or disclose my personal health
information for the purpose of carrying out treatment or payment. I understand that I have the
right to restrict how my personal health information is used and disclose for treatment, payment
and administrative operations if I notify the practice. I also understand that Southwest Physical
Therapy & Rehabilitation, Ltd. will consider requests on a case by case basis, but does not have
to agree to requests for restrictions.
I hereby agree that I am financially responsible for payment of services rendered by Southwest
Physical Therapy & Rehabilitation, Ltd and consent to t the use and disclosure of my personal
health information for purposes noted in the Southwest Physical Therapy & Rehabilitation, Ltd
Notice of Policies and Patient Information Practices. I understand that I retain the right to revoke
this consent by notifying the practice in writing at any time.
PATIENT NAME
SIGNATURE OF PATIENT OR
LEGAL GUARDIAN AND RELATIONSHIP
DATE
CANCELLATION/NO SHOW POLICY
As a provider of excellent care to you and all of our clients, it is very important that
appointments are kept in order to comply with physician orders for an effective recovery. It is
the responsibility of each patient to attend each scheduled appointment. If an unexpected event
occurs proper notification is expected prior to the scheduled appointment.
 There will be a $25.00 fee for not attending scheduled appointments without
notification.
 There will be a $50.00 fee for more than 3 consecutive cancellations.
I the undersigned, have read, understand and agree to the above policy with full responsibility as
stated:
Patient_______________________________________________ Date___________________
Medicare Cap - 2012
Dear Patients,
The following information should help explain the 2012 Medicare financial limitations and how
it will affect your therapy.
What is the dollar amount of the therapy cap for 2012?
From January 1, 2012 to December 31, 2012, the dollar amount allowed is $1880 for physical
therapy and speech language therapy combined and $1880 for occupational therapy.
Which providers are subject to the $1880 cap?
The $1880 cap applies to outpatient therapy services furnished by rehab agencies, physician’s
offices, comprehensive outpatient rehab facilities and physical therapists in private practice.
Does the cap apply to hospitals?
No. The $1880 cap does not apply to services furnished directly or under arrangements by a
hospital to an outpatient or an inpatient who is not in a covered Part A stay. The limitation will
apply to outpatient rehabilitation services furnished by a separately-certified hospital based
provider, such as a hospital based SNF.
Is the cap a per beneficiary cap, a per diagnosis cap or a per provider cap?
According to the Medicare legislation, the $1880 cap is per beneficiary per year. It does not
apply per diagnosis.
What portion of the $1880 is Medicare’s responsibility and what is the patient’s
responsibility?
If the patient has already met his/her Medicare deductible (which is $140.00), Medicare will pay
80% of the $1880 = $1504. The beneficiary will be responsible for 20% of $1880 = $376, which
may be billed to the patient’s secondary insurance.
Once the patient reaches the therapy cap, what are the patient's options?
One option for the patient is to receive therapy in an outpatient hospital department. Any therapy
services provided in the outpatient department of a hospital are not subject to the therapy cap.
You are financially responsible for any amount that Medicare and/or your secondary do not
cover. We are available to keep you informed of your financial status regarding the cap. It is
your responsibility to inform us if you have had any other physical or speech therapy on or after
January 1, 2012.
Our staff is here to answer any questions you may have or you may call me directly at 708-4994497.
Sincerely,
Southwest Physical Therapy
Medicare Cap
By signing below, I agree that I have read and understand the
information given to me regarding the Medicare Cap beginning January
1, 2012. I understand that it is my responsibility to inform Southwest
Physical Therapy of any other therapy services performed on or after
January 1, 2012. I also understand that I am financially responsible for
any charges not paid by Medicare and/or my secondary insurance.
Print Patient Name
Patient Signature
Date