Patient Financial Responsibility
We will ask you to sign and date a copy of this form at your first appointment to acknowledge your understanding of our patient financial policies.

1. The patient (or guardian, if patient is a minor) is ultimately responsible for the payment for treatment and care.
2. We accept our Gift Certificates, Cash or Credit Cards.  We also accept Insurance as defined below:

Insurance (Health, Workers' Comp, Auto, or Accident) used for payment:
Our record in collecting from Insurance Companies is not very good (not good for all Massage Therapists.)  But we will still try.  Massage Therapy on the same day as any other treatment will not be reimbursed by the insurance company and so is a cash payment.

1. You will need a current prescription for Massage Therapy from a primary Health Care Provider, such as a Physician or a Chiropractor in order to submit your claim.  The prescription must:
   • Have your Name
   • Physician or Chiropractor name, NPI, and date.
   • Physician or Chiropractor Address and phone number
   • Your Diagnosis Code(s)
   • Specifically state Massage Therapy for _?_ Minutes, _?_ Times a Week, for _?_ Weeks.
   • Be signed by the Physician or Chiropractor.
2. We will bill your insurance company for you, however the patient is required to provide the most correct and updated information regarding insurance.
3. Patient is responsible for payment of Specialist Co-pays, coinsurance, deductibles and all other procedure or treatments not covered or approved by their insurance plan.
4. Co-pays are due at the time of service.
5. In the event your insurance company denies payment or makes a partial payment you agree to be and remain responsible for the balance.  Therefore, after the lesser of
   1. 2 attempts to collect from an insurance company
   2. 30 days after the first attempt: It is the patient or guardian's responsibility to pay for all services provided, that is for payment of all procedures, coinsurance, deductibles and non-covered items.  
6. If any insurance payment is received after the patient has paid the bill (see #5), the patient will be reimbursed some or all of their payments based on what the insurance company has issued.
7. Please note, charges are based on the Usual and Customary (UCC) Rates for Medicare for the year in which the Massage Therapy is performed.

Arrival Policy:

1. We will ask you to sign and date this form at your first appointment to acknowledge your understanding of our Arrival Policy.
2. We ask you to have the forms filled out, as provided on the Website, prior to your visit.
3. ​We ​request that you arrive 12-15 minutes prior to your <first> appointment to allow time to fill out additional paperwork as well as answer any intake questions your therapist may have.  On subsequent appointments 5-7 minutes early will be fine.  Note: We have added pertinent paperwork to our website.  Please fill it out and submit a copy,  We expect you to still arrive a tad early to finish any paperwork that involves physical pen and paper, such as drawing circles around where it hurts.  We know some people are sensitive about what information they provide over the web, our site is https <<< the "s" is for security.  If you are still uncomfortable, please put something into the field to keep the form happy, and then tell us the real answer when you arrive.  Paperwork is for your and our protection.
4. We understand that issues can arise that may cause you to be late for your appointment.  However, we ask that you call to inform us if this ever occurs so we can do our best to accommodate you.  Appointment times are reserved for each patient, so oftentimes we cannot exceed that reserved time without making the next patient late.  As of now, please do not "Google" Beth Ann's Therapeutic Massage, as the result will be our closed office in Millcreek - we are working with Google to correct this, rather go to our location page.
5. For this reason, arriving after your appointment may result in loss of time from your massage so that your session ends at the scheduled time. 
   1. Full Service Fees will be charged even when sessions are shortened due to late arrival. 
   2. In return, we will do our best to be on time, and if we are unable to do so we will add time to your session to make up for our late arrival or adjust the service charge accordingly.

HIPAA

[Beth Ann's Therapeutic Massage]
HIPAA Privacy and Security Policy
Effective Date: [Jan 2, 2019]
Reviewed/Revised: [1/2/20; 1/2/21; 1/2/22; 1/2/23; 1/2/24; 1/2/25]

I. PURPOSE

This policy is established to ensure that [Beth Ann's Therapeutic Massage], as a provider of medical massage therapy services, complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and safeguards the Protected Health Information (PHI) of our clients.

II. SCOPE

This policy applies to all employees, contractors, and volunteers who have access to PHI within [Beth Ann's Therapeutic Massage], including massage therapists, office staff, billing personnel, and administrative personnel.

III. DEFINITIONS

PHI (Protected Health Information): Any information that can identify a patient and relates to their past, present, or future physical or mental health condition or treatment.

ePHI: PHI that is transmitted or stored electronically.

Minimum Necessary Rule: Access to PHI is limited to the least amount of information needed to perform a job function.

IV. USE AND DISCLOSURE OF PHI

Permitted Uses and Disclosures:

1. For treatment, payment, and healthcare operations (TPO).
2. With patient authorization.
3. As required by law (e.g., public health reporting, court orders).


Prohibited Uses and Disclosures:

Disclosure of PHI for marketing or fundraising without specific authorization.

Use of PHI for personal reasons or curiosity.

V. PATIENT RIGHTS

Patients have the right to:

1. Access and inspect their PHI.
2. Request an amendment to their records.
3. Receive an accounting of disclosures.
4. Request confidential communication methods.
5. File a complaint if they believe their privacy rights have been violated.

VI. SAFEGUARDS

Physical Safeguards:

Files containing PHI are stored in locked cabinets.

Patient intake forms and notes are secured when not in use.

Access to treatment areas is restricted to authorized personnel only.


Technical Safeguards:

Computers are password-protected and timed to log off automatically.

Electronic records are stored on encrypted, secure systems.


Administrative Safeguards:

Staff receive training on HIPAA compliance.

A designated HIPAA Privacy Officer oversees implementation and compliance.

Access to PHI is role-based and tracked.

VII. BREACH NOTIFICATION

In the event of a data breach involving unsecured PHI:

The affected individual(s) will be notified within 60 days.

The U.S. Department of Health & Human Services (HHS) will be notified as required.

An internal investigation will be conducted and corrective measures implemented.

VIII. EMPLOYEE RESPONSIBILITIES

Maintain confidentiality at all times, both in and out of the office.

Report any suspected breaches immediately to the HIPAA Privacy Officer.

Complete mandatory HIPAA training upon hire and annually thereafter.

IX. DISCIPLINARY ACTION

Violation of this policy may result in disciplinary action, up to and including termination, depending on the severity and nature of the breach.

X. CONTACT INFORMATION

HIPAA Privacy Officer: [Beth A Borecky]
Phone: [(814) 873-6324]
Email: [[email protected]]
Office Address: [7870 West Ridge Road, Unit 8, Fairview PA  16415]

This policy is reviewed annually and updated as necessary to ensure continued compliance with HIPAA regulations and industry best practices.

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