Patient Intake Form

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Please read carefully for information regarding ‘Self-pay Wellness Services’ and ‘Insurance Covered services’ and select applicable option

RESPONSIBILITIES OF SELF-PAY WELLNESS SERVICES

I acknowledge that I am choosing to participate in Cash-pay Wellness Service with All-in-All Neuro Rehab & Wellness. I elect to receive these services voluntarily and accept full financial responsibility for all services rendered.

I understand that wellness services are non-billable, not insurance-eligible, and strictly self-pay. I am fully responsible for all wellness service fees at the time of service. Any unpaid balance that becomes delinquent may be subject to collection, and I assume full liability for all associated costs, including collection fees and reasonable attorney’s fees.

RESPONSIBILITIES OF INSURANCE COVERED SERVICES

I elect to use my insurance benefits for my care and authorize All-in-All Neuro Rehab & Wellness to bill my insurance for services rendered on my behalf.

I understand that I must immediately notify All-in-All Neuro Rehab & Wellness of any change in my insurance coverage, including transitions to an HMO, Medicare Advantage plan, or Managed Care Organization (MCO). I acknowledge that I am financially responsible for all charges incurred if I fail to provide timely notification or if coverage is denied by my insurance plan.

I agree to pay any service charges not reimbursed by my insurance carrier or third party payer. If I do not maintain active insurance coverage, I understand that I am responsible for the full cost of services and will pay all balances within 48 hours of receiving notice.

I understand that receiving any overlapping in-home skilled services (ie: Home Health) at the same time I am receiving services from All-in-All Neuro Rehab is a direct violation of the terms and conditions governing the use of my insurance benefits and constitutes a breach of contract for both the patient and the provider. This includes, but is not limited to, Physical Therapy, Occupational Therapy, Speech Therapy, Skilled Nursing, and Wound Care. 

I acknowledge that any violation of the above will result in automatic insurance claim denials, and I accept full financial responsibility for all charges incurred during any period of overlap. I further understand that any delinquent balance may be referred to collections or litigation, and I am liable for all associated costs, including collection fees and reasonable attorney’s fees.

By signing below, I acknowledge that I understand and agree to these personal financial and insurance-use responsibilities.

CONSENT TO SERVICE

I consent to receive rehabilitation therapy, wellness services, and any related treatments deemed appropriate by my clinician. I understand that rehabilitation and wellness care are not exact sciences, and no specific outcome or guarantee of results can be promised. I acknowledge that my treatment plan may evolve based on my response to care and clinical judgment.

CANCELLATION & ATTENDANCE POLICY

At All in All Neuro Rehab & Wellness, your appointment time is reserved specifically for you. Because our clinicians travel across the metroplex and carefully structure their schedules to accommodate each patient’s needs, we ask that all appointment changes be made with a minimum of forty-eight (48) hours’ notice.

Appointments canceled or rescheduled less than 48 hours in advance, as well as missed appointments (“no-shows”), will be charged $150.00. These fees are the sole responsibility of the patient and cannot be billed to insurance or any third-party payor.

We understand that unforeseen situations may arise. However, to remain fair and consistent for all patients, cancellation fees must be paid within three (3) business days. If payment is not received within this timeframe, all future appointments will be removed from the schedule until the balance is resolved.

This policy exists to protect the time, preparation, and travel committed by our clinicians, and to ensure that appointment slots remain available for patients who need care. Consistent attendance is essential for safe and effective progress, and honoring scheduled appointments allows us to provide the highest level of care to every patient we serve.

By signing below, I acknowledge that I have read, understand, and agree to comply with the above Cancellation & Attendance Policy, and I understand how it supports fairness, accountability, and continuity of care for all patients.

PATIENT HIPAA AUTHORIZATION FORM

Our Notice of Privacy Practice provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to revise our Notice before signing this form. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. 

By signing this form, you acknowledge our use and disclosure of protected health information about you for treatment, and health care operations. You have the right to revoke this disclosure, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Acknowledgement Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

The patient understands that:

• Protected health information may be disclosed or used for treatment, or health care operations

• The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.

• The Practice reserves the right to change the Notice of Privacy Practices.

• The patient has the right to restrict the use of their information, but the Practice does not have to agree to abolish.

• The patient may revoke this authorization in writing at any time and all future disclosures will then cease.

• The Practice may condition receipt of treatment upon execution of this Authorization. 

I acknowledge that I have read the above authorization and have access to read All in All Neuro Rehab and Wellness Full Notice Privacy Practices.

Patient Communication Form

I hereby give permission to All-in-All Neuro Rehab and Wellness to notify me by phone, text message, or email regarding the following:

• Appointment reminders, either by personal message or recorded message.

• Messages requesting that I contact my all personnel regarding my care, treatment, or progress.

  
  

I authorize All-in-All Neuro Rehab and Wellness to disclose medical information pertaining to my diagnosis, treatment, medical history, or other related healthcare information to the individuals listed below (physician, family member, caregiver, or other designated representative).

The duration of this authorization shall remain in effect indefinitely unless revoked by me in writing.

I understand and authorize the release of my medical information to healthcare providers involved in my care when necessary to facilitate treatment, coordination of care, payment, or healthcare operations.

I further understand that requests for medical information from individuals not listed above will require my specific authorization prior to the disclosure of such information, unless otherwise permitted or required by law.

NOTICE OF PRIVACY PRACTICE: YOUR INFORMATION. YOUR RIGHTS. OUR RESPONSIBILITIES

YOUR RIGHTS: 

• Get an electronic /paper copy of your medical record: You can ask to see or get a copy of your medical records 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 14 days of your request.

• Ask us to correct your medical record: You can ask us to correct health information about you that is incorrect or incomplete. We reserve the right to say “no” to your request, however will tell you why in writing within 30 days.

• Request confidential communications: You can ask us to contact you in a specific way (home, cell, work number) or to send mail to a different address.

• Ask us to limit what we use and what we share: You can ask us not to use/share health information for treatment, or our operations. We are not required to agree to your request if it affects your care.  

• Get a list of those with whom we’ve shared information: You can ask for a list of the times we’ve shared your health information for 6 years prior to the date you ask, who we shared it with, and why.

• Get a copy of Privacy Notice: You can ask for a paper copy of this Notice at any time.

• Choose someone to act for you: 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 were violated: You can complain if you feel we have violated your rights by contacting us using the following information: U.S. Department of Health and Human Services Office for Civil Rights, 200 Independence Ave, S.W., Washington, D.C. 20201, or call 877-696-6775, or visiting WWW.HHS.GOV/OCR/PRIVACY/HIPPA/COMPLAINTS. We will not retaliate against you for filing a complaint.  

OUR USES AND DISCLOSURES:

We may share your health information in the following ways:

• Treat you: We can use your information and share it with other medical professionals who are treating you.

• Run our organization: We can use your information to run our clinic, improve your care, and contact you when necessary.

• Comply with the law: We will share information about you if state or federal laws require it, including if the Department of Health and Human Services wants to see that we are complying with federal privacy laws. We can share health information about you in response to court or administrative order, or in response to a subpoena.

• Help with public health and safety issues: We will share information about you to help prevent disease, help with product recalls, reporting adverse reactions to medications, reporting suspected abuse/neglect/domestic violence, or preventing/reducing serious threat to anyone’s health or safety. 

• Do research: We will share your information for health research.                             

 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.

• We will not use/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. 

CHANGES TO 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.