TERMS OF SERVICE

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. 

By booking your appointment and receiving therapy services at Ocean Myofascial Release, you are consenting to the following terms and conditions related to the physical therapy services provided by Jessica Padilla, PT, DPT. Please read and understand the details of this Informed Consent document, which outlines the potential risks, benefits, and alternatives to the treatments you will receive.

Treatment and Services Provided

• John F. Barnes' Myofascial  Release (MFR): This is the primary method of treatment used at Ocean Myofascial      Release. Other techniques such as functional mobilization, therapeutic      exercise, Proprioceptive Neuromuscular Re-education (PNF),      Visceral and Neural Manipulation, Pilates, and other manual therapy techniques may also be employed, depending on your condition and the agreed-upon treatment plan.
• Pelvic Floor MFR: In some cases, it may be necessary to perform internal pelvic floor MFR. This procedure includes internal examination and treatment of pelvic floor structures and may involve areas such as the vagina or rectum. You have      the right to stop the treatment at any time and to request a second person in the room during the procedure, if desired.

Participant Responsibilities

• Cooperation: You are expected to cooperate fully with your therapist during the evaluation and treatment process.
• Privacy and Comfort: While you may be asked to disrobe for certain treatments, your therapist will respect your privacy,      modesty, and dignity at all times. If at any point you feel uncomfortable, you may stop the procedure or request another therapist.
• Disclosure: You are responsible for disclosing all relevant medical history, medications, treatments, and diagnoses to your therapist before treatment to ensure that care is coordinated and compatible.

Potential Risks

Physical therapy may involve certain risks, and while efforts are made to minimize any adverse outcomes, you should be aware of the following potential risks:

• Increased pain or discomfort: It is common to experience an      increase in pain or discomfort during or after the treatment. This is typically temporary and should subside within 48-72 hours. If discomfort persists beyond this period, you agree to contact your therapist.
• Other risks: Although rare, risks may include swelling, dizziness, fainting, nausea, cardiovascular problems (such as chest pain or heart attack), or other injuries. If you experience any serious symptoms, such as chest pain or difficulty breathing, you agree to seek immediate medical attention and inform your therapist.

Potential Benefits

• Improved mobility: MFR therapy may improve your      movement, flexibility, strength, and endurance.
• Pain relief: Many patients experience decreased pain and discomfort following treatment.
• Wellness: Therapy aims to enhance your overall wellness by improving your body’s ability to perform daily activities      with ease.

Alternatives

If you choose not to undergo physical therapy at Ocean Myofascial Release, you should discuss your medical, surgical, or pharmacological alternative options with your primary care physician or healthcare provider.

Consent to Treat

By booking and attending your appointment, you provide your authorization for treatment under the scope of the California Physical Therapy Practice Act. You acknowledge that you have been informed of the treatment options available, including the potential risks and benefits, and give your consent for the therapist to proceed with care.

Assumption of Risk and Indemnity

• Assumption of Risk: By participating in therapy, you knowingly assume any risks involved in the treatment, especially since      the services provided at Ocean Myofascial Release may differ from      conventional physical therapy.
• Release and Hold Harmless: You agree to release,  indemnify, and hold harmless Jessica Padilla, PT, DPT and Ocean      Myofascial Release from any liability, damage, or injury arising out of the therapy services you receive, including referrals to other      practitioners or services.

Arbitration Agreement

Any disputes arising out of or relating to this agreement will be resolved through arbitration, as outlined by the American Health Lawyers Association Dispute Resolution Service, with arbitration to occur in Redwood City, CA. This clause also waives the right to a jury trial.

Photographic Consent (Optional)

• Postural Assessments: You may be asked to allow      photographs to be taken of your posture during the initial evaluation, progress evaluations, and discharge summaries. These photos may be used for postural comparisons and educational purposes. By booking your appointment, you consent to the use of these photographs.

No Warranty

While your therapist will provide professional opinions and treatment plans, no guarantees or promises of a cure are made regarding the results of your physical therapy.

Withdrawal of Consent

You have the right to refuse or withdraw consent for any treatment or procedure at any time during your therapy. You are free to discontinue therapy without fear of reprisal.

Acknowledgement

By booking and attending your appointment, you acknowledge and agree to the following:

1. You understand the risks, benefits, and alternatives to physical therapy treatment.
2. You understand your rights and responsibilities as a participant in the therapy process.
3. You agree to work collaboratively with your therapist to achieve the best outcomes for your health.
4. You consent to receive physical therapy treatment under the terms outlined in this document.

If you have any questions or concerns about this consent or the treatment process, please feel free to discuss them with your therapist before beginning treatment.

 If you are a minor, please note that your parents or legal guardians may be legally entitled to certain information about your treatment.

Your therapist will have a discussion during your first appointment with you and your parents or guardians to determine which information is appropriate for them to receive. We will also review which aspects of your treatment are better kept confidential and how we can ensure your privacy is respected while still adhering to legal and ethical obligations.

The goal is to maintain open communication and provide care that is both supportive and respectful of your privacy and well-being.

By scheduling an appointment with Ocean Myofascial Release (Ocean MFR), you acknowledge and agree to the following policies:

Standard Session Length & Session Modifications

• Standard Session Duration: The typical treatment session for Myofascial Release Therapy (MFR) is 60 minutes.
• Custom Session Length: You have the flexibility to determine the length of your session based on your needs. However, requests      to extend or modify the standard 60-minute session must be discussed in advance with your provider to ensure proper scheduling.
• Additional Charges: If you opt for a session longer  than 60 minutes, you will be charged based on the hourly rate of      the service provided. The additional time will be billed accordingly.
• Informed Consent: Prior to your treatment, you must read and sign the informed consent document in person. If you are a new patient, your first session will include time to discuss and sign this form before treatment begins.  

Scheduling and Communication

• Booking Appointments: Appointments must be[MT3]  scheduled via our online booking system (Acuity Scheduling) which is      located on our booking web page. Directions to book are outlined on this page  Alternatively, you may contact Ocean      MFR by email: info@oceanmfr.com or phone (call or text): (650) 826-2601 if you have difficulties with booking online. 
• Response Time: If you contact us via email:      info@oceanmfr.com or phone: (650) 826-2601, we will get back to you within 1-2  business days to confirm or discuss your appointment.
• Changes to Appointments: If any changes need to be made      to your appointment, you are responsible for notifying us within 48 hours. Ocean MFR reserves the right to notify you of any potential cancellations due to unforeseen events such as illness or other catastrophic events within 24 hours of your scheduled time.

No-Show Policy

No-Show Responsibility: Ocean MFR is not responsible for communicating appointments booked on your behalf. If someone else schedules an appointment on your behalf, it is their responsibility to inform you of the scheduled appointment details. 

• No-Show Fee: If you fail to show up for your scheduled appointment without prior notice, the full session fee will be charged to the recipient.

These policies are in place to ensure a smooth and efficient scheduling process and to maintain a high standard of care for all our clients. If you have any questions or need assistance with scheduling, feel free to reach out to us.

Thank you for your cooperation!

To ensure the best care and respect for all clients and therapists, we have established the following 48-Hour Cancellation Policy:

Cancellation Notice

• 48-Hour Notice: If you need to cancel or reschedule your appointment, we kindly ask for 48 hours' notice or more.
• No Charge for cancellations made 48 hours or more in advance. You will also have the opportunity to reschedule your appointment at a convenient time.

Late Cancellations & No-Shows

• Late Cancellations: If you cancel your appointment less than 48 hours before the scheduled time or fail to attend the      appointment (no-show), you will be responsible for the full fee of the missed session.

How to Cancel or Reschedule

• Online Cancellations: Appointments can be canceled or      rescheduled via the Acuity Booking System.
• Text/Email: Alternatively, you can contact us via text: (650) 826-2601 or email: info@oceanmfr.com  to cancel or reschedule your appointment.

We appreciate your understanding and cooperation with this policy, as it allows us to provide consistent care and respect for all our clients.

 To ensure all clients receive the full benefit of their sessions and to be considerate of other appointments, we kindly ask that you arrive on time for your scheduled appointment.

Late Arrival

• Late Arrival: If you arrive late for your scheduled session, the time lost will be deducted from your treatment time.
• Additional Time: If you would like to extend your session by up to 15 minutes, an additional fee will be charged based on the hourly rate for the service provided.

We encourage you to arrive a few minutes early to get settled in and ensure a smooth, uninterrupted session.

If you anticipate you will be late, please notify us via cal or text at (650) 826-2601.    

By booking an appointment with Ocean MFR, you acknowledge and agree to the following terms regarding payment and insurance:

Payment Policy
 

• Payment Due at Time of Service: Payment for all services      rendered is due at the time of service.
• Accepted Payment Methods: We accept the following forms      of payment: 
  • Cash
  • Check
  • FSA/HSA
  • Credit/Debit Cards
• No Refunds: All sales are final. Refunds     are not available for any services rendered.
• Charges: Charges for services provided      are determined by Ocean MFR and must be paid in full at the time of      treatment.

Insurance and Out-of-Network Policy

• Out-of-Network Provider: Ocean MFR is an out-of-network provider. We do not participate in any insurance panels and do not accept assignment from any insurance company.
• Insurance Responsibility: The recipient of MFR therapy is      responsible for understanding and obtaining any necessary information from their insurance company before receiving services. This includes obtaining an estimate of benefits for physical therapy services, including MFR therapy.
• Super bill and Documentation: Upon request, your therapist      will provide a receipt or super bill outlining the services you received. It is the recipient's responsibility to submit this  receipt or super bill directly to their insurance company for reimbursement. 
• If your insurance company requires additional documentation, it will be provided, but there may be an additional fee for such services.
• No Guarantee of Reimbursement: Ocean MFR does not guarantee that you will receive reimbursement from your insurance company, even if you submit the receipt or super bill for services provided.

For detailed information please refer to our FAQs page under "Do you take health insurance?"

Non-Participating Insurance Plans

• Private Insurance: We do not bill insurance      directly. Payment for services is due at the time of treatment, and we provide a superbill (a detailed invoice) that clients can submit to their insurance company for potential reimbursement. However, we cannot guarantee reimbursement from your insurance provider.
• Auto Accident Liens: Ocean MFR does not accept auto      accident liens for payment.
• Workers' Compensation: Ocean MFR does not participate in Workers' Compensation Insurance.
• Medicare: Ocean MFR does not accept Medicare or Medicaid insurance for services.
• Personal Injury Patients: We do not accept personal  injury insurance or claims related to personal injury accidents.

By understanding and agreeing to these policies, you are acknowledging your financial responsibility for the services provided. We encourage you to reach out to your insurance provider before scheduling to ensure that you fully understand your coverage options, as Ocean MFR cannot be held liable for denied claims.

Key Details:
 

1. Time Frame for Use:

• 6-Session MFR Therapy Package: Must be used within 180 days (6 months) from the date of purchase.
• 12-Session MFR Transformation Package: Must be used within 180 days (6 months) from the date of purchase.
  
   

2. Frequency of Treatments: Consistent attendance is essential for achieving your health goals. Regularly scheduled sessions ensure steady progress toward your desired outcomes.

3. Use It or Lose It: Unused sessions after the designated time frame will be forfeited. It is the client’s responsibility to schedule appointments. 

4. Multiple Packages: You may purchase multiple packages at once to maintain momentum in your healing journey. However, each package must be used within its respective time frame. 

5. Non-Transferable: Packages are non-transferable and cannot be shared with or assigned to other individuals.

6. Final Sales Policy: All package sales are final. Refunds are not offered under any circumstances.

Please ensure that you are able to commit to the required frequency of treatments and the package time frame before purchasing. If you have any questions or concerns, feel free to discuss them with your therapist.

At Ocean Myofascial Release, we understand that ending a therapeutic relationship can be challenging. It is important to approach this process thoughtfully to ensure clarity and closure for both the client and the therapist. The appropriate length of termination and the process will depend on the nature and duration of the treatment.

Termination Process

• Therapist Initiated Termination: If the therapist determines      that the treatment is no longer effective, or if the client is in default      on payment, they may initiate the termination of treatment. However, this will only be done after a discussion with the client to explore the reasons for termination and ensure mutual understanding.
• Client Initiated Termination: If you choose to discontinue      treatment or request another provider, we will assist you by providing a list of qualified MFR therapists or help you find another provider through external referral sources.
• Closure and Communication: The therapist will ensure a      process for closure, which may include a final evaluation or recommendations for continued care.

Inappropriate Behavior

• Zero Tolerance Policy: Inappropriate, threatening, or violent behavior towards any member of the Ocean Myofascial Release team will not be tolerated. If such behavior occurs, the professional relationship will be terminated immediately, and treatment will cease without further discussion. Any remaining sessions will not be refunded and cannot be transferred to another individual. 

We strive to maintain a safe, professional, and respectful environment for all clients. If you have any questions or concerns regarding your treatment, please don’t hesitate to reach out to your therapist for a conversation before making any decisions regarding termination.