TERMS OF SERVICE

The term “informed consent” means that the potential risks, benefits, and alternatives of physical therapy treatment have been explained to me. The therapist provides a wide range of services, and I understand that I will receive information at the initial visit concerning the treatment and options available for my condition. The term "I" refers to the recipient of MFR therapy services. 

Ocean Myofascial Release therapy specializes primarily of John F. Barnes' Myofascial Release Approach and treatment forms that are published or otherwise publicly known. Other forms of traditional physical therapy in the forms of functional mobilization, therapeutic exercise programs, Proprioceptive Neuromuscular Re-education (PNF), as well as other treatment modalities, may be used. Your therapist will review your plan of care and discuss these treatment options with you in order for you to provide specific consent. Symptoms may also change and move to other parts of the body. This is not unusual, and it is rarely a concern. However, please ask if you have any concerns or questions. The number of treatments needed and recovery time can both vary due to the duration of injury, number of times injured, age of patient and many other contributing factors.

The recipient is expected to cooperate fully with the evaluation and treatment program. Because of the nature of the services provides, you may be asked to disrobe. If this is necessary, your privacy, modesty and dignity will be considered at all times by the staff. Should you feel uncomfortable or embarrassed, you may refuse the procedure, stop the procedure and/or request another therapist. 

I understand, acknowledge and affirm that such rehabilitation and related services may involve body contact, touch and/or direct contact of a sensitive nature. I understand that to evaluate my condition, it may be necessary to have my therapist perform intra-oral and/or internal pelvic floor MFR. 

Pelvic Floor MFR. This examination is performed by observing and/or palpating internal pelvic floor structures and then performing treatment in the perineal region including the vagina and/or rectum. I understand that I can terminate the evaluation and/or treatment at any time. I understand that if I would like a second person present in the room during examination and/or treatment, then I will provide that person during my session and verbally let my therapist know that. 

You will be able to stop treatment if you feel any discomfort or pain. Your physical therapist will take every precaution to ensure that you are protected from any potentially hazardous situation. You will never be forced to perform any procedure that you do not wish to perform.

Potential risks. I understand I may experience an increase in my current level of pain or discomfort, or an aggravation of my existing injury. This discomfort is usually temporary. If it does not subside in 48-72 hours, I agree to contact my physical therapist.  Other risks include, but are not limited to, swelling, edema, dizziness, fainting, nausea, falling, cardiovascular problems including heart attack, chest pain, and problems breathing. Also, I may experience or incur new injuries during physical therapy; if it does not subside within 24 hours or if it is a serious injury then I agree to contact my physical therapist and seek immediate medical treatment if required or if I experience a serious symptom such as chest pain or heart attack. 

Potential benefits. Benefits may include an improvement in my symptoms and an increase in my ability to perform my daily activities. I may experience increased strength, awareness, flexibility and endurance in my movements. I may experience decreased pain and discomfort. I should gain a greater knowledge about managing my condition and the resources available to me.

Alternatives: If I do not wish to participate in the therapy program, I will discuss my medical, surgical or pharmacological alternatives with my physician or primary care provider.

Consent to Treat. I hereby give authorization for the performance of such rehabilitation procedures as permitted by the State of California, Department of Consumer Affairs, Physical Therapy Board under the California Physical Therapy Practice Act (Cal Bus. & Prof. Code, sections 2600 et al.) and relevant sections of the California Code of Regulations (16 Cal. Code Regs., sections 1398 et al.) under the appropriate scope of practice are, in the judgment of my Therapist, deemed necessary.

My Participation. I understand that Jessica Padilla, PT, DPT dba Ocean Myofascial Release and I are to work as a team on my overall wellness. This requires me to be an active participant for best outcomes, I am responsible to disclose Ocean Myofascial Release all medication, care, treatment, diagnoses, and assessments that I receive elsewhere and to provide medical records from other providers to ensure that care is coordinated and compatible. Medical records can only be released with my authorization I will need to obtain any records that I would like Jessica Padilla, PT, DPT dba Ocean Myofascial Release to review.

(OPTIONAL) Photographs of standing postural assessment during initial evaluation, progress evaluation and discharge summary will be used for postural comparison purposes and as educational tools. By booking this appointment, I consent to the use of these photographs in a professional manner.

No warranty. Jessica Padilla, PT, DPT dba Ocean Myofascial Release will share with me her opinions regarding potential results of physical therapy treatment for my condition and will discuss treatment options with me before I consent to treatment. Jessica Padilla, PT, DPT dba Ocean Myofascial Release cannot and will not make any promises or guarantees regarding a cure for or improvement in my condition.

Assumption of Risk; Indemnity. I choose to receive care that involves clinical innovation and/or differs from conventional, traditional physical therapy; accordingly, I knowingly, voluntarily, and intelligently assume risks involved in the same. As a result of my assumption of these risks, I agree to release, hold harmless, indemnify, and defend Jessica Padilla, PT, DPT dba Ocean Myofascial Release from and against any and all claims which I (or my representatives) may have for any loss, damage, or injury arising out of or in connection with use of the services described above, or arising out of or in connection with referral to other practitioners or merchants for delivery of any services. Correspondingly, I agree not to pursue a claim against any of the foregoing, merely because I am dissatisfied with the results of the above services.

Arbitration. Any dispute arising out of or relating to this contract or the subject matter thereof, or any breach of this Agreement, including any dispute regarding the scope of this clause, will be resolved through arbitration administered by the American Health Lawyers Association Dispute Resolution Service and conducted pursuant to the AHLA Rules of Procedure for Arbitration.

Judgment on the award may be entered and enforced in any court having jurisdiction. The Arbitration shall be held in Redwood City, CA. The arbitrator(s) shall apply the substantive law of the foregoing state, or federal substantive law where state law is preempted. The arbitrator (s) shall have the power to grant all legal and equitable remedies provided by law and award compensatory damages provided by law, except that punitive damages shall not be awarded. The arbitrator(s) shall prepare in writing on which the award is based. The arbitrator(s) shall not have the power to commit errors of law or legal reasoning. Any judicial review of the arbitrator (s) decision shall be governed by the foregoing state's law. HOWEVER, prior to either party initiating Arbitration of any dispute, the parties agree to attempt mediation of the dispute with a mutually agreeable trained mediator in the above-mentioned city or county. 

EACH PARTY HAS READ AND UNDERSTANDS THIS SECTION, WHICH REQUIRES THE PARTY TO SUBMIT ANY CLAIMS TO ARBITRATION, AND WHICH WAIVES THE PARTY'S RIGHT TO A JURY TRIAL.

I have read and understand the risks involved in physical therapy and agree to fully cooperate, participate in all physical therapy procedures, and comply with the established plan of care. I have been given an opportunity to ask questions, and all my questions have been answered to my satisfaction. I confirm that I have read and fully understand this consent document. In the event of a change in medical status, I understand that my treatment may be modified, stopped, or referred out to the proper practitioner. I am fee to refuse or withdrawal my consent and to discontinue participation in any treatment or service at any time without fear of reprisal against or prejudice to me. 

By booking my appointment, I understand, agree and hereby voluntarily accept all risk and responsibility associated with the services provide and use of the Ocean Myofascial Release facilities located at 80 Eureka Square, Suite 146, Pacifica, CA 94044 or Ocean Myofascial Release located at 2636 Ocean Ave, San Francisco, CA. 94132. I agree to hold Ocean Myofascial Release harmless for claims or damages in connection with treatment. This is a contract between myself and Jessica Padilla, PT, DPT dba Ocean Myofascial Release, and I understand that it is also a release of potential liability.

The standard meeting time for MFR THERAPY is 60 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 60 minute session needs to be discussed with your provider in order for time to be scheduled in advance. Additional time will be charged by the hourly rate of the service provided. 

The recipient is responsible for scheduling an appointment via online booking, or contacting Ocean MFR via email or phone call/text. If communication is through email or phone, your provider will contact you in 1-2 business days. 

Ocean MFR has the right to notify the recipient within 24 hours of their appointment for potential cancellations due to illness, or catastrophic events. 

If the appointment was scheduled by another party, that party is responsible for informing the recipient of MFR therapy for the scheduled appointment. If the intended recipient no-shows to their appointment, the entire fee will be charged. The recipient will have to read and agree to the informed consent in person prior to their treatment. 

All sales are final. Payment is due at time of service. Refunds are not available. We are not a participating provider for any insurance plans, and do not bill insurance. Cash, check, FSA/HSA or credit cards are accepted.

Ocean Myofascial Release is an out-of-network provider for services within this physical therapy practice; Ocean MFR does not participate in any insurance panels, and does not accept assignment from any insurance company. The recipient of MFR therapy is responsible for payment in full at time of services and charges are determined by Ocean Myofascial Release

The recipient of MFR therapy is responsible to call their insurance company ahead of time and obtain any information that is necessary, as well as get an estimate of benefits for physical therapy services. The therapist will provide a receipt, upon request, and it is the responsibility of the recipient to submit to their insurance company. If further documentation is requested, these will be provided with an additional fee.  Ocean Myofascial Release does not guarantee that the recipient will receive any reimbursement from their insurance company, even if they submit a receipt and/or superbill provided Ocean Myofascial Release. 

Ocean Myofascial Release does not accept auto accident liens, Workers' Compensation Insurance, or Medicare Insurance. 

The greatest benefit from therapy is consistent attendance and participation in your plan of care. To be courteous to other clients and our therapists, we require a 48-hour (or greater) notice for cancellations. If the recipient cancels more than 48 hours in advance, they will not be charged and will have the opportunity to reschedule. If the recipient cancels less than 48 hours in advance, or fail to attend a scheduled appointment (no-shows), they are responsible for the entire fee. Appointments may be cancelled by phone. 

To be considerate of other clients and our therapist, you will be treated within your scheduled appointment time frame. If you are late for a session, you may lose some of that session time. If the recipient would like additional time (up to 15 minutes) they will be charged an additional fee based on the hourly rate of the service provided. 

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. Your therapist may terminate treatment after appropriate discussion with you and a termination process if they determine that the treatment is not being effectively used or if you are in default on payment. The therapist will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If treatment is terminated for any reason or you request another provider, a list of qualified MFR therapists will be recommended to you. You may also choose someone on your own or from another referral source. 

Inappropriate, threatening and/or violent behavior will not be tolerated. The professional relationship will be discontinued and terminated immediately. 

Each MFR package must be used within a time span of 90 to 180 days, or 3 to 6 months. Frequency of treatments will help you get closer to reaching your goals. Therefore, if you don't use it, you lose it. You are responsible for reserving your appointments online, or with your therapist. Multiple packages can be purchased at once. Not transferable to other parties. All sales are final. Refunds are not available.

If you are a minor, your parents may be legally entitled to some information about your treatment. The therapist will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information.

As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your information.

We may use and disclosed your medical records only for each of the following purposes: treatment, payment and health care operations.

Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination.

Payment means such activities as obtained reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.

Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

· The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

· The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.

· The right to inspect and copy your protected health information.

· The right to amend your protected health information.

· The right to receive an accounting of disclosures of protected health information.

· The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

I. MY PLEDGE REGARDING HEALTH INFORMATION:

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

· Make sure that protected health information (“PHI”) that identifies you is kept private.

· Give you this notice of my legal duties and privacy practices with respect to health information.

· Follow the terms of the notice that is currently in effect.

· I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a health care provider were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the health care provider in diagnosis and treatment of your condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. Session Notes: I do keep “Session notes” and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

a. For my use in treating you.

b. For my use in training or supervising associates to help them improve their clinical skills.

c. For my use in defending myself in legal proceedings instituted by you.

d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

e. Required by law and the use or disclosure is limited to the requirements of such law.

f. Required by law for certain health oversight activities pertaining to the originator of the session notes.

g. Required by a coroner who is performing duties authorized by law.

h. Required to help avert a serious threat to the health and safety of others.

2. Marketing Purposes. As a health care provider, I will not use or disclose your PHI for marketing purposes.

3. Sale of PHI. As a health care provider, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.

Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimes occurring on my premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

7. For research purposes, including studying and comparing the patients who received one form of care versus those who received another form of care for the same condition.

8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9. For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.

10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI. Other than “session notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

5. The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

For more information about HIPAA or to file a complaint:

The U.S. Department of Health & Human Services Office of Civil Rights
 200 Independence Avenue, S.W.
 Washington, D.C. 20201
 (202) 619-0257
 Toll Free: 1-877-696-6775

By booking an appointment.  I have read “Notice of Privacy Practices” as mandated by HIPAA , which describes how my PHI is used and shared. I understand that Jessica Padilla, PT, DPT DBA Ocean Myofascial Release has the right to change this notice at any time.