HANS HUMBERGER PHYSICAL THERAPY at

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1 Hans C. Humberger, PT Nancy Humberger, PT HANS HUMBERGER PHYSICAL THERAPY at THERAPY CONSULTANTS The Results Team Jill Selby, Office Manager Welcome to Therapy Consultants! INFORMATION FOR PATIENT Personal Items & Clothing: Patients are encouraged to wear comfortable clothing when receiving therapy treatments. We have shorts and gowns, at the clinic, for your use during treatment. Appropriate attire typically includes shorts, t-shirts, and gym shoes. Tank tops or halter tops are better for neck and shoulder injuries. Please make sure that the involved body part and surrounding areas are easily exposed. A wash-room is available for clothing changes. Please secure all personal items. Therapy Consultants is not responsible for any lost or stolen items. If items need to be secured, please see the facility manager prior to treatment. Workers Compensation Patients: We appreciate your full cooperation in attending all scheduled therapy sessions. We are required to inform your workers compensation adjuster and/or rehabilitation case manager of all missed or canceled appointments. It is also required that all missed visits be rescheduled. Billing/Payments: All patients co-pays are to be paid on the same day of treatment session unless other arrangements are made with the front office coordinator. All billing questions should be addressed to our front office coordinator. Please inform us immediately if you have made any changes in your address, phone number or insurance carrier. The patient is ultimately responsible for all outstanding balances. Cancellations/No Show Appointments: In order to treat your injury in a timely and efficient manner, you are expected to attend all scheduled therapy visits. All cancellations are to be at least 24 hours in advance, and rescheduled within the same business week whenever possible. There will be a $ charge to all patients who cancel their appointments with less than 24 hour notice, unless that appointment is rescheduled. There will be a $ charge to all patients who do not show up for their scheduled appointments. Three consecutive no shows appointments may result in a discharge. Patient or Guardian Signature As a courtesy to other patients, please do not bring children and spouses into the treatment area. Date Thank you for choosing Therapy Consultants as your physical therapy provider. Our highly skilled staff is looking forward to helping you accomplish your rehabilitation goals in a safe and timely manner Center Street, #104 * Chattanooga, TN * Phone * Fax Therapyconsultants@comcast.net

2 HANS HUMBERGER PHYSICAL THERAPY at THERAPY CONSULTANTS Patient Medical History and Intake Questionnaire Patient Name: Age: Sex: F M Why did you choose this location: What is your main complaint and in what area is it located? Occupation: Are you presently working? Yes No If no - Last day worked: Have you ever had these symptoms before? Yes No If so, when? Have you had physical therapy, occupational therapy or chiropractic care for this injury before? Yes No Which one and when? Check all of those which apply to your current condition: Work Related Injury Sports Injury Fall Motor Vehicle Accident Aggravation of Pre-Existing Injury Causes Unknown Injury Recurrence Lifting Injury Other: What have you been doing to decrease your pain? On a scale from 0 (no pain) to 10 (very severe pain), what is your pain level? Are your symptoms getting worse / better / the same / since your injury? Are you currently taking any medications? (Please list) Are you allergic to any medications? (If yes, please list) Do you have or have you had any of the following? Yes No Yes No Yes No Diabetes Cancer Metal Implants Chest Pain Asthma Dizziness Heart Disease Arthritis Fractures Pacemaker AIDS/HIV Skin Allergies Headaches Allergies to Heat Nausea/Vomiting Kidney Problems Allergies to Cold Ear Ringing Are You Pregnant? Seizures Hypoglycemia Bladder Problems Respiratory Problems High Blood Pressure Have you talked to your Doctor about the problems? Yes No If not may we send this to your Doctor? Yes No Initial If you answered yes to any of the above, please explain and give an approximate date of occurrence: Please circle tests you have had performed: None X Rays MRI CT Scan Bone Scan Other (Explain) Check any of the following activities which you have difficulty with due to your injury: Housekeeping Lifting Driving Shopping Reaching Dressing Cooking Climbing Stairs Child Care Bending Yard Work Sit to Stand List all of your surgeries: Is there any other information about your present health that we should know about? Date Patient or Guardian Signature PT/OT Initials 2255 Center Street, # 104 * Chattanooga, TN * Phone: Fax: Therapyconsultants@comcast.net

3 PATIENT INFORMATION How did you choose this clinic? Today's Date: Facility: Name, Last: First: M.I. Male / Female Address: Apt # City: State: Zip: Cell Phone #: Home #: SS#: Age: Date/Birth: Marital Status: S M D W Student Other Emergency Contact: Name EMPLOYMENT INFORMATION Employer: Address: Full Time / Part Time Work #: MEDICAL INFORMATION Phone: Have you had any therapy provided to you within the last year? Yes No Where: Injured Body Part: Date of Injury/Onset of Symptoms: Work Related: Yes No Accident: Yes No Auto: Yes No If Auto, what State: Referring Physician Name: (Last) (First) Phone: Primary Care Physician: Date of Next Physicians Visit: MEDICARE PATIENTS Have you had any therapy of nursing services in your home? Yes No Medicare ID# PRIMARY INSURANCE Insurance Company: Phone: Subscriber Name: Subscriber Date of Birth: Relationship to Patient: Subscriber Employer: Date of Prescription: Phone: Name of Agency: SECONDARY INSURANCE Insurance Company: Phone: Subcriber Name: Subcriber Date of Birth: Relationship to Patient: Subcriber Employer: ID/Claim #: ID/Claim #: Group #: Group #: ACCIDENT Accident?: Work Related Auto Other Date of Accident: Current Occupation: Insurance Company: Address: State Accident occurred: Phone: ID/Claim #: Adjuster Name: Phone: Employer: Address: Rehabilitation Nurse/Case Manager Phone: Company Name:

4 CONSENT FOR TREATMENT I heareby authorize and give my consent to Therapy Consultants to provide me with physical therapy services. FINANCIAL POLICY Initial Thank you for choosing Therapy Consultants as your physical therapy provider. We will work closely with you and your physician to provide you with treatment. Please understand that timely payment for your treatment is important. Your clear understanding of our financial policy is important to our professional relationship. Cancellation/No show policy: 1. All co-pays and deductibles are due at the time of service. A 24 Hour notice must be received or a fee will be assessed. 2. Payment of patient balance is due in full at the time of service unless other arrangements have been made. If you cannot make full payment at the time of service, please discuss this with our Patient Care Advocate. 3. If any portion of your account balance exceeds 60 days you will be responsible for this amount, plus interest here in at 1 1/2% per month, regardless of your insurance. We accept cash, checks, Visa, MasterCard, Discover and American Express INSURANCE We accept Medicare, all major insurance and numerous PPO and managed care contracts. Please be aware that some, and perhaps all, of the services provided may be considered not medically necessary by your insurance provider. You will be responsible for these charges. Your medical insurance is a contract between you and your insurance company. We are not a party to this contract. Therapy Consultants will submit all claims for charges to your insurance provider as a service to you. Co-pays must be paid at the time of service in order to abide by your insurance contract. If your policy requires a referral, be sure to have it with you when you come to our office. Failure to obtain and present this at the time of service may result in a loss of your insurance benefits. If you need assistance in obtaining a referral, please ask our Patient Care Advocate. To guarantee payment for services rendered, we request documentation of a major credit card. Please provide the following information: Credit Card Type: Master Card / Visa / Discover / American Express Name on Card Card # Exp Date: For your convenience, if you would like your credit card debited weekly for co-pay portion or total charges, please initial here: Date:. Select One: Co-pay Total charge Please be advised that if you are paying by check, Therapy Consultants charges a $35 fee for returned checks. Thank you for understanding our financial policies. If you have any questions or concerns, our Patient Care Advocate will be happy to discuss them with you. I authorize payment of benefits directly to Therapy Consultants for services provided. Signature of Patient (Parent / Guardian, if necessary) Date: Therapist Signature * QUOTATION OF BENEFITS IS NOT A GUARANTEE OF PAYMENT. I hereby authorize Therapy Consultants to release any information necessary to secure the payment of benefits. I also authorize direct payment to Therapy Consultants for any payments due. I authorize the use of this signature on all my claims submissions. I understand that I am financially responsible for all charges whether or not they are covered by insurance. I am fully responsible for any collection fees necessary to collect this account. Patient / Responsible Party Date: Patient Care Advocate / Facility Manager

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6 Hans C. Humberger, PT Nancy Humberger, PT HANS HUMBERGER PHYSICAL THERAPY at THERAPY CONSULTANTS The Results Team Jill Selby, Office Manager Doctor: Address: REQUEST FOR MEDICAL RECORDS Please forward any written reports of x-rays, MRI s and CAT scans. This will help us focus the treatment and help in billing. Thank you for your help. Name: Date: DOB: SSN: Signature: 2255 Center Street, #104 * Chattanooga, TN * Phone * Fax Therapyconsultants@comcast.net

7 Hans C. Humberger, PT Nancy Humberger, PT HANS HUMBERGER PHYSICAL THERAPY at THERAPY CONSULTANTS The Results Team Jill Selby, Office Manager PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION By signing this authorization, I authorize Therapy Consultants to use and/or disclose certain protected health information (PHI) about me to the following doctors: 1. Name and address of entity to receive this information 2. Name and address of entity to receive this information 3. Name and address of entity to receive this information 4. Name and address of entity to receive this information The information will be used or disclosed for the following purpose: To keep additional doctors informed of currant therapy treatment. If requested by the patient, purpose may be listed as at the request of the individual. The purpose(s) is/are provided so that I can make an informed decision whether to allow release of the information. This authorization will expire on the date of discharge from Therapy Consultants. I do not have to sign this authorization in order to receive treatment from Therapy Consultants. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the Privacy Official at: 2255 Center Street, Suite # 104 * Chattanooga, TN Signed By: Signature of Patient or Legal Guardian Patient s Name Relationship to Patient Date Print Name of Patient or Legal Guardian 2255 Center Street #104 Chattanooga Tn Phone Fax Therapyconsultants@comcast.net

8 Hans C. Humberger, PT Nancy Humberger, PT Dear Patient: HANS HUMBERGER PHYSICAL THERAPY at THERAPY CONSULTANTS The Results Team Jill Selby, Office Manager INFORMED CONSENT FOR PHYSICAL THERAPY Physical therapy involves the use of many different types of physical evaluation and treatment. At Therapy Consultants, we use a variety of procedures and modalities to help us to try and improve your function. As with all form of medical treatment, there are benefits and risks involved with physical therapy. Since the physical response to a specific treatment can vary widely from person to person, it is not always possible to accurately predict your response to a certain therapy modality of procedure. We are not able to guarantee precisely what your reaction to a particular treatment might be, nor can we guarantee that our treatment will help the condition you are seeking treatment for. There is also a risk that your treatment may cause pain or injury, or may aggravate previously existing conditions. You have the right to ask your physical therapist what type of treatment he or she is planning based on your history, diagnosis, symptoms and testing results. You may also discuss with your therapist what the potential risks and benefits of a specific treatment might be. You have the right to decline any portion of your treatment at any time before or during your treatment session. Therapeutic exercises are an integral part of most physical therapy treatment plans. Exercise has inherent physical risks associated with it. If you have any questions regarding the type of exercise you are performing and any specific risks associated with your exercises, your therapist will be glad to answer them. I acknowledge that my treatment program has been explained by Therapy Consultants, and all of my questions have been answered to my satisfaction. I understand the risks associated with a program of Physical Therapy as outlined to me, and I wish to proceed. (print) Patient Name Patient Signature Date PT Signature Date 2255 Center Street, #104 * Chattanooga, TN * Phone * Fax Therapyconsultants@comcast.net

9 Hans C. Humberger, PT Nancy Humberger, PT HANS HUMBERGER PHYSICAL THERAPY at THERAPY CONSULTANTS The Results Team Jill Selby, Office Manager Notice of Privacy Practices Date: Patient Name (Print): Location: I received a copy of the NOTICE OF PRIVACY PRACTICES. (PATIENT or GUARDIAN Signature) I authorize the release of appointment information left on the voic or message center at: Home Phone Number: Cell Phone Number: Work Phone Number: Initial 2255 Center Street, #104 * Chattanooga, TN * Phone * Fax Therapyconsultants@comcast.net

10 Hans C. Humberger, PT Nancy Humberger, PT HANS HUMBERGER PHYSICAL THERAPY at THERAPY CONSULTANTS The Results Team Jill Selby, Office Manager WELCOME LETTER NAME: DATE: I have received the welcome letter and helpful hints. Signing this is my record that you received it. Thanks! God Bless, Hans and Nancy 2255 Center Street, #104 * Chattanooga, TN * Phone * Fax Therapyconsultants@comcast.net

11 Hans C. Humberger, PT Nancy Humberger, PT HANS HUMBERGER PHYSICAL THERAPY at THERAPY CONSULTANTS The Results Team Welcome Letter Jill Selby, Office Manager We want to welcome you here to Therapy Consultants. We are honored that you and your physician have elected to send you to us to help you. Nancy and I have been physical therapists since 1979 and have had numerous opportunities to work with patients with all types of diagnoses. We have worked with patients as young as 18 months clear to 103 years of age. Each of the patients that Nancy and I have seen over the years has many diagnoses and problems. Physical therapy is designed to evaluate and identify the mechanical, neurological, and muscular components to the problem, and then look for rehabilitation solutions to that end. Over the years, some new modalities and treatment techniques have been added, but in essence we are looking for problems of postural mechanical changes, tightnesses, weaknesses, that cause an inflammatory process whether the injury is of trauma, of repetitive use, or weakness through the aging process. The list of causes are many: Be it arthritis, trauma, birth defects, acquired injuries through repetitive use, worker s comp injuries, but what Nancy and I look for are common threads of lack of circulation, nerve impingement, weaknesses, soft tissue contraction, and immobility to treat to help resolve the pain pattern and loss of function. We then prescribe a program specific for your problem that you can carry out at home. Then you, Nancy and I will work together to modify the program each time you come in to achieve the greatest results. You have to make the sacrifice (temporary) of the Time, Talent and Treasures to get better faster. Faith without work is dead. Therefore work in HIS name to show you have the faith to get better. Without Gentle Consistent Work No Results Will Be Seen. Helpful Hints: 1. We recommend drinking lots of water. The medical literature indicates that increased water intake flushes the waste products away from the injured and inflamed area. When a muscle stays in active spasm it produces a tremendous amount of waste products, which will cause an increase in pain. Also, when we have decreased fluid intake, the muscle system dries out, and you can lose up to 50% of your power and 75% of tissue flexibility. 2. We encourage you to gently massage the problem areas. One to three minutes of gentle massage to each area that is tender and tight will increase circulation. Increased circulation allows for muscle relaxation, increased nutrients, oxygen and food to the muscles. Also, massage increases the flexibility of the tendons, capsules, ligaments and muscles allowing fluid movement like an accordion, all the way in and all the way out. This causes decreased joint compression, which further relaxes the muscles and takes the pressure off of arthritic conditions and inflamed regions. 3. We recommend the use of cold or heat to increase the circulation in problem areas. We find that cold packs used for 2 to 10 minutes in a small area will increase the circulation faster than heat. This is particularly good over muscle attachments to bones, joint and other problem areas such as a bulging disc or facet problems in the low back. We find when there are large areas of pain such as neck or low back, most people like heat better because it gently increases the circulation of more muscles. Usually, heat will take anywhere from 15 to 30 minutes to generate the increase in circulation and body temperature, to relax the muscles and flush the waste products out. We recommend doing this 3-5 times a day or more. It is the change in skin temperature that increases circulation. Unless your

12 physician/dentist has specific instructions to alternating heat and cold, our facility recommends 30 minutes between cold or heat treatments so as not to damage the skin and tissues. Remember; gentle and consistent is faster. 4. A walking program is beneficial with most diagnoses (i.e., fibromyalgia, low back, or neck problems.) Your physician will encourage you to walk to improve strength and circulation. We have found walking is a great way to increase aerobic capacity, increase circulation, and overall leg and hip strength. But, most patients go out and overdo it and walk far too long the first time. The real problem is that most of us that are coming to therapy have anywhere from 1-10 muscles or joints that are injured, and cannot move correctly. Those muscles fatigue in a hurry, (i.e., by the time you walk from your car into Wal-Mart you are already tired.) This fatigue leads to increased waste products, changes in circulation, and increased pain. Sometimes the increase in pain is so great that you are incapacitated for hours or days while the inflammation and swelling decreases. Therefore, in a walking program, we start gently with a stroll. What you can do comfortably, and then increase gentle and consistently from there. Start with walking one minute twice a day, at a very gentle pace like you were walking up the aisle at church saying hello to everybody. If you can walk, talk and move freely without hurting for a minute, then on the next day add one minute and go to two minutes of walking morning and night. Again, it is not about how far, it is time. Muscles need time for greater circulation and to build strength. If on the second day you did very well without an increase in pain or soreness, then the third day add a minute and walk three minutes in the morning and three minutes in the evening. As long as this is successful continue to add 1 minute per day. Be patient with your progress. This way, you can consistently work up to 30 minutes twice a day at a leisurely pace in 30 days. This hour of exercise has been shown to burn calories, slowly increase the strength so you can have greater endurance, and have better circulation. Walking builds strength along with the exercises you do here at the office, and the core and home exercises that you are doing. They are all important. If you try to push the program, you will hurt yourself and this will set you back. Remember; gentle and consistent is faster. 5. The core exercises that we are teaching you have all helped somebody s pain to be decreased or eliminated. The problem is you don t know which exercise is going to help you the most. Therefore, we recommend that you do all of our exercises gently two to three repetitions per hour. Remember, I do not want your soreness from the exercises to last more than two hours. If the pain has increased after two hours, then you have done too much, too hard, too far, or too something let Hans and Nancy help you figure out what is going on in your life to cause the fatigue and pain. Remember; gentle and consistent is faster. 6. Prevent fatigue. Most people come to our office with a problem area or areas, (i.e., my back hurts ). We start treatment, and you begin to feel better. You go back to normal activity, or try to catch up on activities that pain prevented. The temptation is to do too much too soon; and you come to us saying I did nothing, and my back hurts worse. Proper body mechanics and core stabilization are both very easy to do AND also easy to not do. Old habits (arching your back or squeezing your knees together) take time to replace with better body mechanics. Therefore, you need to work with your therapist to establish what is the baseline of activity that you can do without hurting? Prevent fatigue. Do the exercises and get stronger with more endurance. Remember; gentle and consistent is faster. Remember, when your body has pain, it is a signal to the brain that something is working too hard. The brain is trying to get you to rest. Generally, we have fatigued the problem area by the time it starts to hurt. Usually, the fatigue has started anywhere from 20 minutes to two hours before you actually realize it. So, it is not that there is something new causing you to hurt; it may be that the simple stuff is still too much for the injured area. Remember, you have to have stability before you have mobility. Incorrect body mechanics can be starting increasing pain as you stand up and walk across the room. Therefore, we recommend that you rest, increase the circulation, and gently do the exercises to strengthen the area. Then you will find your muscles, ligaments, and joints will allow you to do more and more with less and less pain.

13 7. Degenerative joint change. We find with arthritis that many of us over the age of 13 have changes in our bones and joints, as shown by x-rays. Some people have a lot of pain with arthritis, and some have very little, but most all of us over the age of 13 can have some sort of degenerative joint change. Arthritis, especially osteoarthritis, comes from injuries to our joints and muscles where the joint surfaces come together. The joint capsule tightens up, creating friction. This friction causes destruction of cartilage, which are the bone changes seen on x-rays. With swelling and heat, the joint capsule tightens, causing more joint compression. With tight capsules there is a reflexive loop from the joint capsules back to the muscles, contracting the muscles to try to make less friction and shortening the joint capsule. Joints do not like to have tight joint capsules, so it causes the muscles to contract around the joints again to relax the joint capsule. The only problem is, this muscle contraction leads to greater pressures, more destruction of the bone and cartilage, therefore osteoarthritis increases. Massaging gently the joint area to increase soft tissue mobility helps. One to three minutes per joint. Then let us show you the proper exercises to be done to increase the flexibility and strength. Remember; gentle and consistent. No pain, gain. 8. For healthy posture, the spine has to be strong enough to support the head and the pelvis. All the muscles that attach to the spine have to stabilize so you can move your body. So, with each mechanical, postural mechanical and neurological problem we treat, we are going to teach you the core exercises to strengthen the spine for a healthy life that keeps you independent and moving until you are 142 years old. Remember; gentle and consistent. 9. Keep moving. I worked with Hospice of Chattanooga for over five years. What I learned is people want to keep moving. I had very few people complain of the dying process. What they complained about most is the inability to get out of a chair, recliner, wheelchair, or hospital bed and not to be able to take care of themselves. This loss of independence is their Number #1 problem. We will be working with you to eliminate those problems. We want you to have great health all of your life. Therefore, every day chin tucks, tummy tucks, scaption, wall pushups, and the application of proper standing and breathing are the activities that you need to do daily to stay healthy for the rest of your life. Nancy and I want you to be independent for all of your life, to be active as long as you want, so you can serve and follow God s call. 10. You need increased circulation to help problems heal frequently during a day. If you were an athlete on a professional team and we were hired to be your therapist we would be treating you anywhere from 4-10 times a day to get you back out on the field and into action. The training staff would not give you a choice of Oh, I m too busy and have to go home to feed the dog. You would be in the training room, working to solve your problems so you can get back out into life s action, which in this case would be playing professional basketball, or football, or soccer. Therefore, at home, you have two roles. One is to be your own therapist to remind you every hour to do something to increase your circulation so you can heal faster, and two, if problems develop, keep track of them and bring them to your therapist at Therapy Consultants where we can figure out what it is that is causing fatiguing and pain. Remember; gentle and consistent is faster. 11. No Pain! No Gain! Does not work for pain. Ask why? See the staff. No Pain! Gain! Gentle and Consistent! Helpful Hints to Hold Costs Down: 1. Do the Above. Remember, Gentle and Consistent works Faster. You re in charge at Home. 2. Work consistently to improve as fast as we can. In this day and age of reimbursed health care, (Insurance companies, Medicare, Medicaid) are decreasing reimbursements on a day by day basis. What the insurance companies want to see from you (the client) and Therapy Consultants is that we develop a plan of action, getting agreement from your physician, and then we work consistently to

14 improve as fast as we can. Therefore, if you have any concerns about money, please make those arrangements ahead of time. We can meet a budget if you need one. 3. All insurance companies want to see the plan of treatment carried out in a very timely manner with progress. So, the questions we ask and the exercises and self-care activities we ask you to do at home are to maximize your improvements in the shortest amount of time possible. So, we ask you to sacrifice (give up) those activities at home that make you worse, so that you can rest, increase the circulation and treat yourself during the course of the day to improve. We do get new orders every 30 days if we have to see you past the first four weeks. All the physicians that we work with want to maximize your improvements as fast as we can. 4. Insurance companies expect copayments to be paid as you go along. Insurance companies expect you to make your deductible payments as part of your contract with them. We will collect those as you are treated. We will make estimates because insurance companies have different write offs. Balances will be billed. 5. ATTENDANCE: Please try to keep your appointments because this will speed your recovery and allow you to improve faster. Remember Gentle and consistent produces the greatest results. All insurance companies want you to attend therapy regularly. Please cancel as early as you know, to let someone else have your spot. We are busy. If you cancel or miss, please reschedule. Excessive cancellations or missed appointments may lead to a missed appointment charge. Please do not make us do this. If you have financial concerns please see the office manager. Only she has the authority to work out a payment plan. Thank you, Hans. Finally: It will be a pleasure for Nancy, I, and the staff at Therapy Consultants to get to know you. We have met many great people over the years and have come to know many of their family members. We as a staff like to get results. We would like to help you achieve results, and we would like to help your friends and family. If we can help in any way, please call. It is not about a clipboard and exercises and being in a room with four other patients doing the exercises. My staff and team want to spend one on one time with you to focus on your problem. We need your help at home. We need your cooperation. We need your attendance. From Amos 3:3 NIV: Do two walk together, unless they have agreed to do so? So, from the Bible we want to agree with you to go forward and work hard to get you better. So you can have the life that God called you to have spiritually, physically, emotionally. Then, as we work through this, if something does come up, that we need to improve, Matthew 5:25 says Settle matters quickly. Let us talk to improve the situation sooner, so we can help improve your life the way God would like us to. Please call me (423) directly if you have needs or questions. God Bless, Hans and Nancy Humberger, PT & the Staff at Therapy Consultants 2255 Center Street, #104 * Chattanooga, TN * Phone * Fax Therapyconsultants@comcast.net

15 THERAPY CONSULTANTS Notice of Privacy Practices Effective Date: December 6, 2010 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. If you have any questions about this notice, please contact our privacy officer: Jill Selby, Office Manager THERAPY CONSULTANTS 2255 Center Street., Suite 104 * Chattanooga, TN Summary of Rights and Obligations Concerning Health Information. Therapy Consultants is committed to preserving the privacy and confidentiality of your health information, which is required both by federal and state law. We are required by law to provide you with this notice of our legal duties, your rights, and our privacy practices, with respect to using and disclosing your health information that is created or retained by Therapy Consultants. Each time you visit us, we make a record of your visit. Typically, this record contains your symptoms, examination and test results, our assessment of your condition, a record of your treatment interventions, and a plan for future care or treatment. We have an ethical and legal obligation to protect the privacy of your health information, and we will only use or disclose this information in limited circumstances. In general, we may use and disclose your health information to: plan your care and treatment; provide treatment by us or others; communicate with other providers such as referring physicians; receive payment from you, your health plan, or your health insurer; make quality assessments and work to improve the care we render and the outcomes we achieve, known as health care operations; make you aware of services and treatments that may be of interest to you; and comply with state and federal laws that require us to disclose your health information. We may also use or disclose your health information where you have authorized us to do so. Although your health record belongs to Therapy Consultants, the information in your record belongs to you. You have the right to: ensure the accuracy of your health record; request confidential communications between you and your therapist and request limits on the use and disclosure of your health information; and request an accounting of certain uses and disclosures of health information we have made about you. We are required to: maintain the privacy of your health information; provide you with notice, such as this Notice of Privacy Practices, as to our legal duties and privacy practices with respect to information we collect and maintain about you; abide by the terms of our most current Notice of Privacy Practices; notify you if we are unable to agree to a requested restriction; and accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. We reserve the right to change our practices and to make the new provisions effective for all your health information that we maintain. Should our information practices change, a revised Notice of Privacy Practices will be available upon request. If there is a material change, a revised Notice of Privacy Practices will be distributed to the extent required by law. We will not use or disclose your health information without your authorization, except as described in our most current Notice of Privacy Practices. In the following pages, we explain our privacy practices and your rights to your health information in more detail. Page 1 of 5

16 2. We may use or disclose your medical information in the following ways: A. Treatment. We may use and disclose your protected health information to provide, coordinate and manage your rehab care. That may include consulting with other health care providers about your health care or referring you to another health care provider for treatment including physicians, nurses, and other health care providers involved in your care. For example, we will release your protected health information to a specialist to whom you have been referred to ensure that the specialist has the necessary information he or she needs to diagnose and/or treat you. B. Payment. We may use and disclose your health information so that we may bill and collect payment for the services that we provided to you. For example, we may contact your health insurer to verify your eligibility for benefits, and may need to disclose to it some details of your medical condition or expected course of treatment. We may use or disclose your information so that a bill may be sent to you, your health insurer, or a family member. The information on or accompanying the bill may include information that identifies you and your diagnosis, as well as services rendered, any procedures performed, and supplies used. Also, we may provide health information to another health care provider, such as an ambulance company that transported you to our office, to assist in their billing and collection efforts. C. Health Care Operations. We may use and disclose your health information to assist in the operation of our practice. For example, members of our staff may use information in your health record to assess the care and outcomes in your case and others like it as part of a continuous effort to improve the quality and effectiveness of the healthcare and services we provide. We may use and disclose your health information to conduct cost-management and business planning activities for our practice. We may also provide such information to other health care entities for their health care operations. For example, we may provide information to your health insurer for its quality review purposes. D. Students. Students/interns in rehabilitation or health service related programs work in our facility from time to time to meet their educational requirements or to get health care experience. These students may observe or participate in your treatment or use your health information to assist in their training. You have the right to refuse to be examined, observed, or treated by any student or intern. If you do not want a student or intern to observe or participate in your care, please notify your provider. E. Business Associates. Therapy Consultants sometimes contracts with third-party business associates for services. Examples include answering services, transcriptionists, billing services, consultants, and legal counsel. We may disclose your health information to our business associates so that they can perform the job we have asked them to do. To protect your health information, however, we require our business associates to appropriately safeguard your information. F. Appointment Reminders. We may use and disclose Information in your medical record to contact you as a reminder that you have an appointment. We usually will call you at the home and/or the cell phone number provided the day before your appointment and leave a message for you on your answering machine or with an individual who responds to our telephone call. However, you may request that we call you only at a certain number or that we refrain from leaving messages and we will endeavor to accommodate all reasonable requests. G. Treatment Options. We may use and disclose your health information in order to inform you of alternative treatments. H. Release to Family/Friends. Our staff, using their professional judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, your health information to the extent it is relevant to that person s involvement in your care or payment related to your care. We will provide you with an opportunity to object to such a disclosure whenever we practicably can do so. We may disclose the health information of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law. However, please note that under state law, if a child age eighteen (18) or older requests that their medical information not be disclosed to a parent or guardian, we must comply with their request. Please let your provider know if you would like us to release information to a family member or friend. I. Health-Related Benefits and Services. We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you. In face- to-face communications, such as appointments with your provider, we may tell you about other products and services that may be of interest you. J. Newsletters and Other Communications. We may use your personal information in order to communicate to you via newsletters (including electronic newsletters), mailings, or other means regarding treatment options, health related information, disease management programs, wellness programs, or other community based initiatives or activities in which our practice is participating. Page 2 of 5

17 K. Disaster Relief. We may disclose your health information in disaster relief situations where disaster relief organizations seek your health information to coordinate your care, or notify family and friends of your location and condition. We will provide you with an opportunity to agree or object to such a disclosure whenever we practicably can do so. L. Marketing. In most circumstances, we are required by law to receive your written authorization before we use or disclose your health information for marketing purposes. However, we may provide you with promotional gifts of nominal value. Under no circumstances will we sell our patient lists or your health information to a third party without your written authorization. M. Public Health Activities. We may disclose medical information about you for public health activities. These activities generally include the following: licensing and certification carried out by public health authorities; prevention or control of disease, injury, or disability; reports of births and deaths; reports of child abuse or neglect; notifications to people who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; organ or tissue donation; and notifications to appropriate government authorities if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will make this disclosure when required by law, or if you agree to the disclosure, or when authorized by law and in our professional judgment disclosure is required to prevent serious harm. N. Food and Drug Administration (FDA). We may disclose to the FDA and other regulatory agencies of the federal and state government health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing monitoring information to enable product recalls, repairs, or replacement. O. Research. We may disclose your health information to researchers when the information does not directly identify you as the source of the information or when a waiver has been issued by an institutional review board or a privacy board that has reviewed the research proposal and protocols for compliance with standards to ensure the privacy of your health information. P. Workers Compensation. We may disclose your health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law. Q. Law Enforcement. We may release your health information: in response to a court order, subpoena, warrant, summons, or similar process of authorized under state or federal law; to identify or locate a suspect, fugitive, material witness, or similar person; about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person s agreement; about a death we believe may be the result of criminal conduct; about criminal conduct at Therapy Consultants; to coroners or medical examiners; in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime; to authorized federal officials for intelligence, counterintelligence, and other national security authorized by law; and to authorized federal officials so they may conduct special investigations or provide protection to the President, other authorized persons, or foreign heads of state. R. De-identified Information. We may use your health information to create "de-identified" information or we may disclose your information to a business associate so that the business associate can create de-identified information on our behalf. When we "de-identify" health information, we remove information that identifies you as the source of the information. Health information is considered "de-identified" only if there is no reasonable basis to believe that the health information could be used to identify you. S. Personal Representative. If you have a personal representative, such as a legal guardian, we will treat that person as if that person is you with respect to disclosures of your health information. If you become deceased, we may disclose health information to an executor or administrator of your estate to the extent that person is acting as your personal representative. Page 3 of 5

18 T. Limited Data Set. We may use and disclose a limited data set that does not contain specific readily identifiable information about you for research, public health, and health care operations. We may not disseminate the limited data set unless we enter into a data use agreement with the recipient in which the recipient agrees to limit the use of that data set to the purposes for which it was provided, ensure the security of the data, and not identify the information or use it to contact any individual. 3. Authorization for Other Uses of Medical Information. Uses of medical information not covered by our most current Notice of Privacy Practices or the laws that apply to us will be made only with your written authorization. You should be aware that we are not responsible for any further disclosures made by the party you authorize us to release information to. If you provide us with authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization, except to the extent that we have already taken action in reliance on your authorization or, if the authorization was obtained as a condition of obtaining insurance coverage and the insurer has the right to contest a claim or the insurance coverage itself. We are unable to take back any disclosures we have already made with your authorization, and we are required to retain our records of the care that we provided to you. 4. Your Health Information Rights. You have the following rights regarding medical information we gather about you: A. Right to Obtain a Paper Copy of This Notice. You have the right to a paper copy of this Notice of Privacy Practices at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy. B. Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. This includes medical and billing records. To inspect and copy medical information, you must submit a written request to our privacy officer. We will supply you with a form for such a request. If you request a copy of your medical information, we may charge a reasonable fee for the costs of labor, postage, and supplies associated with your request. We may not charge you a fee if you require your medical information for a claim for benefits under the Social Security Act (such as claims for Social Security, Supplemental Security Income, and any other state or federal needs-based benefit program). If your medical information is maintained in an electronic health record, you also have the right to request that an electronic copy of your record be sent to you or to another individual or entity. We may charge you a reasonable cost based fee limited to the labor costs associated with transmitting the electronic health record. C. Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we retain the information. To request an amendment, your request must be made in writing and submitted to our privacy officer. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend formation that: was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the medical information kept by or for Therapy Consultants; is not part of the information which you would be permitted to inspect and copy; or is accurate and complete. If we deny your request for amendment, you may submit a statement of disagreement. We may reasonably limit the length of this statement. Your letter of disagreement will be included in your medical record, but we may also include a rebuttal statement. D. Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures of your health information made by us. In your accounting, we are not required to list certain disclosures, including: disclosures made for treatment, payment, and health care operations purposes or disclosures made incidental to treatment, payment, and health care operations. However, if the disclosures were made through an electronic health record, you have the right to request an accounting for such disclosures that were made during the previous 3 years; disclosures made pursuant to your authorization; disclosures made to create a limited data set; disclosures made directly to you. Page 4 of 5

19 To request an accounting of disclosures, you must submit your request in writing to our privacy officer. Your request must state a time period which may not be longer than six years and may not include dates before April 14, Your request should indicate in what form you would like the accounting of disclosures (for example, on paper or electronically by e- mail). The first accounting of disclosures you request within any 12 month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the accounting of disclosures. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time, before any costs are incurred. Under limited circumstances mandated by federal and state law, we may temporarily deny your request for an accounting of disclosures. E. Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. If you paid out-of-pocket for a specific item or service, you have the right to request that medical information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we are required to honor that request. You also have the right to request a limit on the medical information we communicate about you to someone who is involved in your care or the payment for your care. Except as noted above, we are not required to agree to your request. If we do agree, we will comply with your request unless the restricted information is needed to provide you with emergency treatment. To request restrictions, you must make your request in writing to our privacy officer. In your request, you must tell us: what information you want to limit; whether you want to limit our use, disclosure, or both; and to whom you want the limits to apply. F. Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by . To request confidential communications, you must make your request in writing to your provider or our privacy officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. G. Right to Receive Notice of a Breach. We are required to notify you by first class mail or by (if you have indicated a preference to receive information by ), of any breaches of Unsecured Protected Health Information as soon as possible, but in any event, no later than 60 days following the discovery of the breach. Unsecured Protected Health Information is information that is not secured through the use of a technology or methodology identified by the Secretary of the U.S. Department of Health and Human Services to render the Protected Health Information unusable, unreadable, and undecipherable to unauthorized users. The notice is required to include the following information: a brief description of the breach, including the date of the breach and the date of its discovery, if known; a description of the type of Unsecured Protected Health Information involved in the breach; steps you should take to protect yourself from potential harm resulting from the breach; a brief description of actions we are taking to investigate the breach, mitigate losses, and protect against further breaches; contact information, including a toll-free telephone number, address, Web site or postal address to permit you to ask questions or obtain additional information. In the event the breach involves 10 or more patients whose contact information is out of date we will post a notice of the breach on the home page of our Web site or in a major print or broadcast media. If the breach involves more than 500 patients in the state or jurisdiction, we will send notices to prominent media outlets. If the breach involves more than 500 patients, we are required to immediately notify the Secretary. We also are required to submit an annual report to the Secretary of a breach that involved less than 500 patients during the year and will maintain a written log of breaches involving less than 500 patients. 5. Complaints. If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C To file a complaint with us, contact our privacy officer at the address listed above. All complaints must be submitted in writing and should be submitted within 180 days of when you knew or should have known that the alleged violation occurred. See the Office for Civil Rights website, for more information. You will not be penalized for filing a complaint. Page 5 of 5