COMPANY POLICIES | Therapeutic

Notice of Information Practices and Privacy Statement

How We Collect Information About You: Therapeutic Innovations LLC. (TILLC) and its employees and volunteers collect data through a variety of means including but not necessarily limited to letters, phone calls, emails, voice mails, and from the submission of applications that is either required by law, or necessary to process applications or other requests for assistance through our organization.
What We Do Not Do With Your Information: Information about your financial situation and medical conditions and care that you provide to us in writing, via email, on the phone (including information left on voice mails), contained in or attached to applications, or directly or indirectly given to us, is held in strictest confidence.
We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about applicants or clients who apply for or actually receive our services that is considered patient privacy is confidential, that is restricted by law, or has been specifically restricted by a patient/client in writing.
How We Do Use Your Information: Information is only used as is reasonably necessary to process your application or to provide you with health or counseling services which may require communication between TILLC and health care providers, medical product or service providers, pharmacies, insurance companies, and other providers necessary to: verify your medical information is accurate; determine the type of medical supplies or any health care services you need including, but not limited to; or to obtain or purchase any type of medical supplies, devices, medications, insurance,
If you apply or attempt to apply to receive assistance through us and provide information with the intent or purpose of fraud or that results in either an actual crime of fraud for any reason including willful or un-willful acts of negligence whether intended or not, or in any way demonstrates or indicates attempted fraud, your non-medical information can be given to legal authorities including police, investigators, courts, and/or attorneys or other legal professionals, as well as any other information as permitted by law.
Information We Do Not Collect: We may use cookies on our website to collect date from our site visitors. We do use some affiliate programs that may or may not capture traffic date through our site.
Limited Right to Use Non-Identifying Personal Information From Biographies, Letters, Notes, and Other Sources: Any pictures, stories, letters, biographies, correspondence, or thank you notes sent to us become the exclusive property of TILLC. We reserve the right to use non-identifying information about our clients (those who receive services or goods from or through us) for fundraising and promotional purposes that are directly related to our mission.
Clients will not be compensated for use of this information and no identifying information (photos, addresses, phone numbers, contact information, last names or uniquely identifiable names) will be used without client’s express advance permission.
You may specifically request that NO information be used whatsoever for promotional purposes, but you must identify any requested restrictions in writing. We respect your right to privacy and assure you no identifying information or photos that you send to us will ever be publicly used without your direct or indirect consent.

INFORMED CONSENT AGREEMENT
I understand that the Massage Therapy given to me by Therapeutic Innovations, LLC is for the purpose of stress reduction, pain management, relief from muscle tension, and increasing circulation. The Massage Therapy I receive at Therapeutic Innovations, LLC is provided by Licensed Professionals, and may use a variety of techniques including but not limited to: Swedish, Deep Tissue, Myofascial Release, Deep Stretch Techniques, Postural Trigger Point Therapy, Reiki, Heat and Cold topical ointments, Therapeutic grade essential oils, cryo-therapy, heat packs, and Kineso Tape, Infared Light Therapy, Watsu Aquatic Therapy.
I understand that all therapy techniques will be discussed with me, and if at anytime I feel uncomfortable, of if pressure or technique is not comfortably tolerable, I will immediately notify the therapist. It is the policy of this company to walk through pain not push through it. During discussions of treatment, subjects of benefits, imitations and contraindications of massage will be addressed as to fully inform client.

Therapeutic Innovations, LLC follows all HIPPA laws and regulations. I have read and received my copy of the privacy policy provided by Therapeutic Innovations, LLC.
Disrobing Policy: Traditionally massage has been known as a hands on- skin on treatment. BUT, it is never required to disrobe to receive massage therapy. It is the policy of Therapeutic Innovations, LLC that all treatments are to be given with the clients comfort and modesty in mind. The client will be left alone during all disrobing and re-robing, and proper draping techniques as defined by the Oregon Board of Massage Therapists, will be used.
I understand the massage therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations a part of massage therapy. I understand that massage therapy is not a substitute for medical care and that is recommended that I work with my primary medical physician for any condition I may have. I understand that Therapeutic Innovations, LLC may collaborate a health care plan with other health professionals, such as a primary care physician, chiropractor, or physical therapy clinic.

ASSIGNMENT OF BENEFITS
I AM RESPONSIBLE FOR ALL CHARGES FOR ALL SERVICES PROVIDED, IN THE UNFORTUNATE EVENT THAT MY INSURANCE COMPANY DENIES PAYMENT, OR MAKES A PARTIAL PAYMENT, I AM RESPONSIBLE FOR ANY BALANCE DUE. IF THERAPEUTIC INNOVATIONS, HAVE CONTRACTED WITH MY INSURANCE COMPANY AND A DISCOUNT RATE FOR SERVICES, THE AMOUNT REMAINING WILL BE WAIVED AND I WILL NOT BE ASKED TO PAY THE BALANCE. I AUTHORIZE AND DIRECT PAYMENT OF MEDICAL BENEFITS AND/OR PRIVATE INSURANCE BENEFITS TO THERAPEUTIC INNOVATIONS, LLC. THERAPEUTIC INNOVATIONS, LLC CHARGES ALL INSURANCE PAYED CLAIMS AT THE STANDARD RATE ALLOWED BY MEDICARE UNDER ITS CURRENT GUIDELINES.

RELEASE OF MEDICAL RECORDS
I authorize the release of medical records or other healthcare information, including intake forms, chart notes, reports, correspondence, billing statements, and other written information to my attorneys, healthcare providers, and insurance case managers for the purpose of processing my claims.

FINANCIAL POLICY
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 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.

INSURANCE FEE SCHEDULE
Our fees are determined by the complexity of each case and different speciality services used, current national Medicare reimbursement rates

Medical/ Auto Fee Rate Revised 03/30/2023
Rates are set and billed at 15 minute increments (1 unit)

* Most sessions are billed in 4 unit increments for bodywork, and additional units for supplemental therapies such as infrared light, or ice therapy. ) Please refer to ASSIGNMENT OF BENEFITS

97113 (USED FOR WATSU BILLING) Aquatic Exercise in a Pool with exercise preformed $45/1 unit

97112 (USED FOR WATSU BILLING) Neuromuscular Re-education training $45 /1 unit

97140 Manual Therapy: $75 / 1 unit. (ADVANCED TECHNIQUES, I.E. MYOFASCIAL RELEASE, STRUCTURAL INTEGRATION)
97124 Massage Therapy: $45 /1 unit
97026 Infrared LIGHT (RICHWAY BIOMAT) $50/ 1 unit
97010 Heat/Ice Therapy $40/ 1 unit

Private (CASH) Pay Fee Rate Revised 03/30/2023

60 MINUTES THERAPEUTIC MASSAGE $120.00

90 MINUTES THERAPEUTIC MASSAGE $150.00

60 MINUTES WATSU® AQUATIC THERAPY $100.00 ( you pay own pool fees)

90 MINUTES WATSU® AQUATIC THERAPY $150

DEBIT/CREDIT CARD FEE $5.00 under $500

MISSED APPOINTMENT FEE : FULL COST OF SESSION.

Regarding insurance:
We will verify coverage prior to treatment and we will file all claims as a courtesy to you. If for any reason we are not able to verify coverage prior to your treatment, you will be charged for the treatment until verification is obtained. We cannot bill your insurance unless you bring us all necessary insurance information. We are not a party to that contract. By signing this document, you are assigning to this office the benefits to which you are eligible to receive for care rendered in this office. Additionally, in signing this document you authorize the release of any information to any insurance company, adjuster or attorney that will assist in the payment of a claim. We request a credit card on file if the insurance company should not pay claims or any balances owed should there be any difference in the amount owed.
Usual and Customary Rates UCR:
Our practice is committed to providing the best treatment possible for our patients. We charge what is usual and customary for our area. Please be aware that some and at times perhaps all of the services may be non-covered services and not considered reasonable and necessary by medical insurance. All payments are due at the time of service.

Missed Appointments:
Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointment at the rate of a normal office visit, the first time your an offender of this rule. Your treatments will be more effective IF you follow your physician's guidelines or your Self- Care Therapy Plan Agreement made in collaboration with your L.M.T, Certified Watsu Therapist and stick to your treatment schedule to the best of your ability.

Please help us to serve you better by keeping your scheduled appointments.

Please let us know if you have any questions or concerns.

I have read the financial policy and I agree to this financial policy ____

OFFICE FINANCIAL POLICY AND AUTHORIZATION TO BILL INSURANCE
There are two billing options available for you. Private pay and Insurance Billing. If at any time if you choose to change your billing option, you are required to let us know immediately and sign a new Office Financial Policy and Authorization to Bill Insurance Form.

Private Pay patients are patients that do not bill insurance. This discounted cash rate is only applied to the published rate if you pay at the time of service.

Insurance Billing (Medical or Auto Insurance)
I understand that I must pay all co-payments and/or co-insurances not covered by my insurance company at the time of check in for today’s visit, and every visit hereafter. THERAPEUTIC INNOVATIONS, LLC will submit my claim for me to my insurance company. Although THERAPEUTIC INNOVATIONS, LLC verifies my insurance; I understand that this verification is not a guarantee of payment. I understand that any and all charges incurred at this office including co-payment, co- insurance, percentage due and/or deductibles or any other fees or services not covered by my insurance company are my responsibility. I understand that if these patient portions due are not paid at the time of service I will be subject to a $10.00 billing fee per month – no exceptions until the outstanding amounts are paid. I further understand that any unpaid balance over 90 days, can and will be sent to collections for recovery unless prior arrangements have been made.
I authorize my insurance benefits to be paid directly to THERAPEUTIC INNOVATIONS, LLC. I also authorize the provider to release any information and medical records required by my insurance company. I understand that I may revoke this consent by written request, at any time. No other records shall be released without my signed consent.

For any questions please contact:
Shauna Athena Samargis LMT 16144

Certified WATSU Therapist
Therapeutic Innovations, LLC
2670 Broadway Ave, PMB#193
North Bend, Oregon 97459
WARMWATERBODYWORK@GMAIL.COM
WWW.THERAPEUTICINNOVATIONS.NET
PH: (541) 294-4491