NOTICE OF PRIVACY PRACTICES

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 health information.

We may use and disclose 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 reJated services by one or more health care providers. An example of this would include a consultation, evaluation, and therapy treatment.

Payment means such activities as obtaining 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 you.

We may also contact you for special occasions or events related to our company and our relationship with 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 and we have the obligation to provide to you a paper copy of this notice from us at your first service delivery date.

The right to provide and we are obligated to receive a written acknowledgement that you have received a copy of our Notice of Privacy Practices.

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

This notice is effective as of April 14,2003, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

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

Please contact us for more information:
Ginger Fitness and Rehabilitation, Inc., Shannan Atkin; Privacy Officer
27553 Cashford Circle, Wesley Chapel Fl33544 813-631-9700

For more information about HIP AA or to file a complaint:
The US Department of Health and Human Services, Office of Civil Rights
200 Independence Ave, SW; Washington, DC 20201; 202-619-0257 or toll free 877-696-6775

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I have read and agreed with the NOTICE OF PRIVACY PRACTICES

Electronic Signature Consent*

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

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Permission to Have Photograph and Video Taken and Utilized

Patient's Name:	DOB:
I,   ,am:
self
authorized to make decisions for the patient named above,
agree to have hislher photograph and/or video taken by either conventional camera or by digital camera, phones, etc, by the authorized epresentative of Ginger Fitness& Rehab., Inc. (GFR) I authorize the perpetual use of the picture/ video(s) without further permission required for the following: To be used for the purpose of a PT/ergonomic evaluation, compiling an exercise booklet or recording and instructions for my own use or as instructions to my caregiver to help me; for the purpose of educating others, including students, health professionals, lay persons, other patients, etc.; for the purpose of announcements and/or advertisement for Ginger Fitness and Rehab. Inc. This could include posting on GFR's website, on flyers, and other places as needed.
Electronic Signature Consent* By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

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AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

This allows us to contact your physician or other healthcare providers for your health information, which will help us treat you more effectively.

Patient's Name:	Date of Brith: Clear
Previous Name:	Social Security #:
I request and authorize (Fill in your provider name)   to release healthcare information of the patient named above to:
Name: Ginger Fitness & Rehabilitation, Inc.
Address: 27553 Cashford Circle, Suite #101
City: Wesley Chapel     State: Florida     Zip Code: 33544
PLEASE FAX THIS INFORMATION TO OUR MEDICAL RECORDS DEPARTMENT AT (813) 631-9770 or email to Office2@GingerFitness.com
This request and authorization applies to: Healthcare information relating to the current diagnosis requiring Physical and/or Occupational Therapy Services to include on going treatment plan, diagnostic procedures, surgical reports or hospitalization. School Related Therapy Services Other: All healthcare information Electronic Signature Consent* By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

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Patient Agreement and Payment Policy

We are committed to providing you with the best care possible and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy or your responsibility.

• We verify your insurance coverage, pre-certification, authorizations, and limitations of visits. Insurance coverage benefits will be explained to you prior to date of services.
• Due at time of service: Co-payments or co-insurance, deductible, patient's % assigned by their insurance policy, and private pay. This must be paid PRIOR to being seen.
• We accept as payment methods: cash/ checks/ credit cards (Visa, MC). There will be a 1% interest charge per month on the unpaid balances (equal to 12.68% Per year). $50 charge for returned checks.
• Missed appointments: We VALUE your time and our staffs. Unless cancelled at least 24 hours in advance, our policy is to charge $80 for Ginger Fitness and Rehab, inc / Charge $150 Grace Adaptive Driving scheduled appointments. We staff accordingly to our patients scheduled.

Explanation about insurance:

Insurance is a contract between you and your insurance company. We are not a party to this contract in most cases. We will inform you if we are accepted providers for your insurance and we will file your claims according to our agreement with the insurance company.

You are responsible for the timely payments of you're account. We file your insurance as a COURTESY to you. Any charge your insurance does not cover is your responsibility. By law, your insurance company has 45 days to pay your charges. If your insurance company has not paid the FULL BALANCE within 45 days, you have 15 additional days to pay the balance. Late payments' charges are added to unpaid accounts after 60 days from the date of service. If your insurance company pays more than the balance due, we will send you a refund check immediately.

Explanation of Medicare benefits: Accepting assignment means that the provider of services agrees to accept the "allowable charges" as determined by Medicare as full payment. However, Medicare only pays 80% of the allowable charge after the yearly deductible has been satisfied. Therefore, you are responsible for any amounts applied toward your annual part B deductible, any non-covered charges and the 20% co-insurance balance. If you have secondary insurance, depending on your contract, you may still be responsible for part of the deductible and/or 20% co-insurance.

Workers Compensation Coverage: GFR agrees to treat and bill worker's compensation for pre-authorized work related injuries per the Worker's Compensation Guidelines for the State of Florida. However, if for any reason Worker's Compensation denies liability for the treatment of the injury, you are responsible for full payment of the charges.

Medicaid/ Champus:
If you are covered by Medicaid, Champus,or any other government sponsored program, please discuss your payment situation with our office manager prior to treatment being provided.

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Consent for Treatment and Acknowledgment of payment policy:

I the undersigned hereby authorize Ginger Fitness and Rehabilitation, Inc., the physical therapist assigned and whomever he/she may designate as his/her assistant(s), to provide therapy services as may be dictated by prudent medical practice of my illness, injury, or condition. This consent is intended as a waiver of liability for such treatment excepting acts of negligence.
I also certify that no guarantee or assurance has been made to the results that may be obtained.

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I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that Ginger Fitness and Rehabilitation, Inc. will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to Ginger Fitness and Rehabilitation, Inc. will be credited to my account upon receipt. I permit Ginger Fitness and Rehabilitation, Inc. to endorse remittances for the conveyance of credit to my account.

HOWEVER, I CLEARLY UNDERSTAND AND AGREE THAT ALL SERVICES PROVIDED ARE CHARGED DIRECTLY TO ME AND THAT I AM PERSONALLY RESPONSIBLE FOR PAYMENT IF MY INSURANCE DOES NOT PAY OR DOES NOT PAY FULLY. I the undersigned, further agree that should interest be levied against this account in accordance with office Policies, I will be responsible for that interest in the amount of 1% per month on the unpaid balance (equal to 12.68% per year). Should collection action in any form become necessary, the undersigned shall be responsible for all collection costs including but not limited to collection agency fees, attorney fees, and any court costs.

Authorization to Release Information:

I authorize the release of any medical information necessaryto process my insurance claim(s) and also certify that all insurance information given to this clinic is correct and complete. I hereby expressly authorize Ginger Fitness and Rehabilitation, Inc. to disclose such information to my insurance company or its authorized representatives and my attorney and his/her agents.

I certify that the information given by me in applying for payment under the Title XVII of the Social Security Act is correct. I authorize Ginger Fitness and Rehabilitation, Inc., to release information regarding my health care to the Social Security Administration, its intermediaries, or any other insurance carrier, or my attorney for this or a related claim.

I expressly and knowingly release Ginger Fitness and Rehabilitation, Inc. from any and all claims, causes of action or duties, known or unknown, which exist or may exist, that arise from or are in any way related to Ginger Fitnessand Rehabilitation, Inc. disclosure of any information concerning my injuries and/or rehabilitation. I understand and acknowledge that this release is perpetual.

Authorization of Payment

I authorize payment from Medicare and/or my Supplemental/Commercial/Government / Workcomp Insurance Company to submit payment by direct deposit or by check. Correspondence with payments will be addressed and mailed to Ginger Fitness and Rehabilitation, Inc., 27553 Cashford Cir., Suite 101, Wesley Chapel, FL33544, for the professional or medical expense benefits allowable, which otherwise would payable to me under my current insurance policy as payment toward the total charges incurred for the professional services rendered.

THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment is not to exceed my indebtedness to the above mentioned assigneeand I have agreed to pay any balance of the said professional service over and above this insurance payment.

A photocopy of this assignment shall be considered effective and valid as the original.

• I agree to ALL information, policies and fees listed in the Financial Policy and Patient Agreement sections above.
• I understand my rights to privacy as stated and have received a copy of the Notice of Privacy Practices.
• I agree that all my information is correct and if there are changes, I will inform Ginger Fitness and Rehabilitation as soon as possible.

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I have read and agreed with the Patient Agreement and Payment Policy

Electronic Signature Consent*

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

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