PATIENT INFORMATION

The Continuum 3700 Grant Dr. Reno, NV 89509

The Continuum 3700 Grant Dr. Reno, NV 89509

(Please note that if you are receiving Home Health Services and your services at The Continuum are denied, you will be responsible for the balance due (Please Initial)

PATIENT RIGHTS AND RESPONSIBILITIES

I am aware that I may be treated in an open area and not in a private treating room. I am aware that I am not to repeat any patient information that does not pertain to me that I may hear while being treated in an open treatment room. A patient has the right to confidentiality whether medical, financial, and/or personal. patient has the right to understand all treatment and treatment options. A patient has the right to receive information contained in medical records. A patient has the responsibility to provide total and accurate billing information. A patient has the responsibility to comply with medical advice and if non-compliant to medical advice, the patient agrees to advise their physician. A patient has the responsibility to understand and abide by The Continuum policies. A patient has the responsibility to ask questions if they do not understand any of their rights and responsibilities.

AGREEMENTIAUTHORIZATION FOR SERVICES

It is necessary for you to comply with your treatment program prescribed by your physician and provided by your therapist. In order for you to achieve the desired results, it is necessary to receive treatment consistently. Cancellations should be made at least twenty four (24) hours in advance of appointment. Our goal is to provide you with the highest quality of treatment. We encourage you to ask questions if the plan is not clear. We also encourage family members to become involved and welcome any comments and suggestions.

AUTHORIZATION AND RELEASE OF INFORMATION

-| authorize The Continuum to release any information including the diagnosis and the records of any treatment or examination rendered during the period of such care to third party payers to facilitate payment of a claim, or the other health practitioners for continuity of care. This includes verbal, written, and faxed releases. -| have been offered a copy of The Continuum's Notice of Privacy Practices (HIPAA I understand that The Continuum has the right to alter its Notice of Privacy Practices from time to time, and I may contact them at any time to obtain the latest version in person or by visiting The Continuum website.

-Cancellation of appointments without 24-hour notice and/or NO SHOW of an appointment may be subjected to termination of your repeat or future appointments.

FINANCIAL POLICY AND GUIDELINES (Please Read & Initial Each)

Thank you for choosing us as your healthcare provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment.

Payment is expected at the time of service, unless prior arrangements have been made. Charges shown by statements are agreed to be correct and reasonable unless protested in writing within thirty (30) days of billing date. Patients who carry medical insurance should remember that all professional services are rendered and charged to the patient, not the insurance company. The obligation for the full payment of this account remains your own and if the insurance company fails to make payment within forty-five (45) days, you will be expected to pay the total balance of this account.

Your insurance policy is a contract between you, your employer and the insurance company. We are NOT a party to that contract. Our relation is with you, not your insurance company. -In special instances, we may accept assignment of insurance benefits, however you are ultimately responsible for the bill. -All charges are your responsibility whether your insurance company pays or not. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services that they will not

Fees for these services, along with unpaid deductibles and copayments are due at the time of treatment. -It is your responsibility to understand copayments, deductibles, and co-insurance and to be aware and inform The Continuum of any changes in your policy. -If the insurance company does not pay in full within forty-five (45) days, we may require you to pay the

balance due with cash, check or credit card.

-Unless an appointment is canceled at least twenty four (24) hours in advance, you may be charged with a cancellation fee based on our current fee scheduled. Please call if you have to reschedule. -A patient has the right to understand all billing and fees. -A patient has the responsibility to provide current, total, and accurate medical history information.

Keep in mind that determination of coverage or approval of pre-authorization under a members benefit plan does not necessarily ensure claim reimbursement.

The Continuum's Attendance and Compliance Policy

Our scheduler will record your dates of therapy in the computer and will print them out for you. It is very important you:

1) Attend all scheduled therapy appointment. Regular sessions show the greatest gains in the shortest amount of time. In order for insurance to pay for these sessions, significant progress must be noted and regular attendance plays a big part. 2) If you do not come for your scheduled appointment and have not canceled at least 24 hours in advance, you will be charged a $50 fee unless you have experienced an emergency or illness. If you must cancel, please try

3) If three or more appointments are missed in a short amount of time, your therapist(s) will discuss removing you from the repeat schedule or discharging. Your program can start up again when appointments are more manageable. If your schedule does not allow for consistent attendance, you may be asked to call daily to see if an opening exists. 4) There will be times that you will be seen by other clinicians due to your clinician being ill, out of town, in training, or an emergency. All of our clinicians are well-trained and will follow any treatment protocol that your evaluation clinician has set as a plan. We love helping people. That is why we chose this profession. But just like you, we have to make a living. Thank you for your understanding and support.

I have read this policy and agree to attend the scheduled therapy visits. I understand that unless an emergency arises, I will be billed a no-show fee if I do not provide 24 hours' notice of cancellation.

For every appointment you have we will be either calling/ texting/ or emailing appointment dates and times as a courtesy. We know it is hard to remember every appointment in our busy lives so we like to make it a little easier on

Please choose ONE of the options below to indicate how you would like to be reminded of your appointment:

1) E-mail 2) Text message 3)Phone Call 4) No reminder

You will receive the reminder phone call/text/ or email 24 hours before your scheduled appointment.

If you have selected no reminder we would like to remind you to give us a call or leave a voicemail at least 24 hours before your scheduled appointment if you need to cancel.

We do understand there are times we need to make last minute cancellations; however, if you are able we greatly appreciate a little notice.

(Please refer to you cancellation policy or front desk staff if you have any questions regarding our cancellation policy) *Standard data fees and text messaging rates may apply based on your plan with your mobile carrier. As mobile access and text message delivery is subject to your mobile carrier network availability, such access and delivery is not guaranteed*