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Notice of Privacy Practices

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.

Get a copy of this privacy notice

  • 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.

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 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.

Your Choices

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.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

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.

Run our organization

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.

Bill for your 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.

Help with public health and safety issues

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

Do research

We can use or share your information for health research.

Comply with the law

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.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

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

Respond to lawsuits and legal actions

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.

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: November 2024

Privacy Official: Rekindle Rehab | [email protected] | Phone #: (240) 240-6223

Email and Texting Messaging Agreement

Rekindle Rehab 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, it is possible that email and text messaging security can be compromised, and it is beyond the control of Rekindle Rehab 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

Rekindle Rehab LLC occasionally gathers photos and videos of the treatment process with clients.

Rekindle Rehab 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 Rekindle Rehab 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 Rekindle Rehab 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." 

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Release of Information

I hereby authorize the release of any information by telephone, email/fax, or in writing, including reports of diagnosis, treatment prognosis, recommendation, benefits payable, as well as any other data pertinent to my treatment, by Rekindle Rehab LLC to the physician who referred me for therapy, and to any organization responsible for payment of my account. I also authorize the release of any information by telephone or in writing for utilization and quality review purposes.

Notice of Privacy Practices

I acknowledge receipt of the Notice of Privacy Practices from Rekindle Rehab LLC. I understand that the Notice of Privacy Practices provides information about how Rekindle Rehab 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 Rekindle Rehab 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 Rekindle Rehab 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 Rekindle Rehab 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.

Medical Payments (Med Pay): If you are injured in an auto accident and choose to use your MedPay benefits you will pay at the time of service and you will be provided a copy of your bill that you can submit to your auto insurance for reimbursement. I understand that I am responsible to pay at time of service and submit my invoice to the auto insurance company.

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 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 Rekindle Rehab 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 Rekindle Rehab 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.

Past Due Accounts/Collection Actions: I understand that payment is expected at time of invoice. I understand that if my account is past due, it can be sent to a collection agency. I understand that Rekindle Rehab LLC is not required to obtain 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. I understand that clients are responsible for paying the collection costs plus court costs and filing fees incurred if collection proceedings or other legal action is necessary to collect payment. 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 Rekindle Rehab 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.

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.

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Informed Consent Form

You have consulted with Rekindle Rehab 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.

You may discuss with your provider the potential risks and benefits of a specific treatment and possible alternative treatment.

Physical and Occupational Therapy: Physical therapy involves several methods of evaluation and treatment. We use a variety of procedures and treatments to help us try and improve your physical and psychosocial function. As with all forms of medical treatment, there are benefits and risks involved. Patient responses to a specific form of treatment can vary widely from patient to patient, and it is not always possible to predict responses to a given form of treatment. There is a risk that your treatment may result in pain, injury, or aggravation of a previous condition.

Speech Therapy: Speech involves several methods of evaluation and treatment. We use a variety of procedures and treatments to help us try and improve your function. As with all forms of medical treatment, there are benefits and risks involved. Patient responses to a specific form of treatment can vary widely from patient to patient, and it is not always possible to predict responses to a given form of treatment. There is a risk that your treatment may result in pain, injury, or aggravation of a previous condition.

You have the right to inquire as to the form of treatment based upon your history, diagnosis, and symptoms.

I hereby agree to release, defend, and hold harmless Rekindle Rehab 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 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. The therapist identified on this form 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. The therapist identified on this form 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 Rekindle Rehab 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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