A NEW "PERSONALIZED" outpatient clinic for ALL ages

 

 

Personalized Therapy, LLC - Providing Occupational & Physical Therapy for Adults & Pediatric in St. Mary's County

 

Before Your 1st Visit Begins, we ask you to read over the following:

 

Welcome to Personalized Therapy, LLC.  We are here to offer you comprehensive Occupational and Physical Therapy Services.

 

Attached you will find several forms that we need for you to read, fill out, and sign.

 

1.  Patient Registration:  Please complete, sign, and return to us.  This form requires you to complete information such as demographics, Insurance, Emergency Contact, Referring and Primary Care Physician Name and Phone Numbers.

 

2.  Benefit Verification:  Please pick up in the office.  Our Business Office completes this information prior to your visit in conjunction with your insurance company.  It includes information such as copay, coinsurance, deductible, if you need a referral, precertification, and how many visits are allowed under your plan.

 

3.  Adult Patient History Form or Pediatric Patient History Form:  Please complete, sign, and return to us.  This form is to educate our Therapists and/or your Insurance Company so that they can better understand your needs.  (If you are a UHC or Medicare Patient please refer below for other forms

 

4.  Patient Assessment for Social/Vocational Assistive Services:  Please read and check all that may apply, sign, and return to us.  Our office collaborates with the Maryland Department of Social Services to ensure that we are accurately reporting our patient’s needs.

 

5.  HIPPA – Please read this very carefully and take this copy for your records.  This form explains how medical information about you maybe used and disclosed and how you can get access to this information. 

 

6.  Authorization for Disclosure of PHI:  Please pick up in the office.  We are required to get your permission to communicate with healthcare professionals, school personnel, etc where it pertains to you or your child’s care.

 

7.  Financial Payment Policy:  Please pick up in the office.  This policy explains important information regarding cancellation fees and your financial responsibility as the insurance holder.

 

8.  Copayment vs. Coinsurance Info:  Please read and take this copy for your records.  This sheet is to help you understand what it means when your insurance company says you have a “copayment” or a “coinsurance payment.”

 

9.  Patient Authorization:  Please pick up in the office.  This Authorization states that you give us permission to treat you, bill your insurance, you have read our HIPPA policy, you have read our Financial policy, and you give us permission to use Media Recording (pictures, videos of you or your child) while you are receiving treatment.

 

For UHC Patients:  

 

10.  Additional Patient History Form:  Please complete, sign, and return to us.  UHC requires that you complete this additional questionnaire on their standard form.

 

For Medicare Patients:

 

10.  Medicare Financial Responsibility Disclosure:  Please read, complete, sign, and return to us.  As a Medicare Provider we are required to inform you about your responsibilities as a Medicare Beneficiary.

 

11.  Therapy Questionnaire:  Please pick up in the office.  Medicare requires that we ask these questions prior to treating new patients.

 

12.  ABN Frequently Asked Questions:  Please pick up in the office.  This Medicare policy explains important information regarding denial of payment by Medicare in some circumstances.

 

13.  ABN Form:  Please complete, sign, and return to us.  We are required to notify you that Medicare does not pay for everything that your Therapist and Doctor deem “Medically Necessary” and that you may be responsible for those charges.

 

 

Thank you for entrusting Personalized Therapy, LLC for your outpatient Occupational and Physical Therapy needs.  We appreciate your business.  If you ever have any questions, please feel free to ask a member of our staff:  Our e-mail address is ot.ptjobs@yahoo.com.

 

 

Occupational Therapy Treatment:  Melanie, Joan, or Heather

Physical Therapy Treatment:  Lisa, Carolyn, or Toby

Scheduling/Intake/Copies:  Mary Kay or Wendy

Business Office (Complaints, Statements, Insurance):  Kristi or Patty

 

 


Personalized Therapy, LLC
22593 Three Notch Rd, Rt. 235
California, MD 20619

Call for an appointment
or free consultation
(301) 862-2505
 

Following Insurances Accepted:

- Aetna

- Blue Cross Blue Shield

- Cigna

- Johns Hopkins Healthcare
o  Employer Health Programs (EHP)
o  Priority Partners (PPMCO)
o  Uniformed Services Family Health Plan (USFHP)

- Medicare

- Tricare Prime

- Tricare Standards