Informed Consent and Policies
Medical Necessity
All treatments must be justified and medically necessary in order for us to treat and bill your insurance. Some of the factors that determine whether or not treatment is medically necessary are:

  • Does your condition interfere with the quality of your life?
  • Does your condition interfere with your ability to perform work or daily activities?
  • Are you motivated and able to participate in your treatment program and follow home and self-care instruction?
  • Is there potential for your condition to improve and/or resolve? If not, is there potential for your function or ability to perform daily activities to improve through modified movement, assistive devices, etc.?
  • Are there specific goals set that are measurable and trackable?

If the above criteria are not met, you are welcome to participate in our elective services such as massage, ergonomics/body mechanics services, fitness/exercise training, tune-ups, MissionFit programs, etc. payable out-of-pocket by cash, check or credit card.

Cancel/No-show/Late
You may lose your appointment if more than 15 minutes late.  We do not allow appointment overlap because this compromises your care and the care of another patient.


If you fail to show for an appointment without 24-hour notice all future appointments will be removed and a $25 fee assessed. You may re-schedule appointments again on a “first come, first serve basis”.  If you wish to change or cancel an appointment we require a minimum 24-hour advance notice. Anything less will result in a $25 fee charged to your account, which is to act as a deterrent from making last minute changes. Advance notice allows someone else time to reserve it in place of you. Please be courteous and responsible.


Cell phones must be shut OFF or silent.


Results
The purpose of physical therapy is to maximize your body’s own healing potential through natural means and promote your ability to perform daily, work, and leisure and sports activities through increased strength, flexibility, agility, and movement strategies. It is not possible to predict the results or outcomes of treatment. Sometimes benefits are realized immediately and sometimes it’s more gradual over time.


An Authorization for Release of Records Assignment of Benefits for insurance patients is obtained in-office.


Insurance Patients
It is your responsibility to know your benefit and insurance coverage for physical therapy services, including any maximums or exclusions. You are responsible for all charges whether paid by insurance or not. Any balances that exceed 30 days may incur fees and collection costs.

Medicare Patients
If you do NOT have supplemental insurance, you will be responsible for the twenty percent (20%) co-insurance portion not paid by Medicare as well as any deductible amounts not yet met. It is your responsibility to keep track of therapy cost totals for the purpose of not exceeding the Therapy Threshold (unless your diagnosis is medically necessary).


Financial Hardship

If you are experiencing financial difficulties and are unable to afford the cost of our services we have a Financial Hardship Form which may be filled-out. If you qualify for financial assistance according to the Federal guidelines, we may legally assist you by waiving or discounting your portion of the bill.  Ask the front desk person for assistance.

Copays are due at the time of service
Important Notice from the Federal Government: “It is unlawful to routinely avoid paying your copay, deductible or coinsurance payments–even if your doctor allows it. Unless you complete a “Financial Hardship” form and qualify for financial assistance under Federal Standards, you may NOT routinely evade paying your responsibility portions for medical care as outlined in your insurance plan even if your doctor allows it. You both may be charged for breaking the law. This includes services deemed as “professional courtesy” and “TWIP’s - Take what insurance pays”. Failure to comply places you in violation of the following laws: Federal False Claims Act, Federal Anti-Kickback Statute, Federal Insurance Fraud Laws, State Insurance Fraud Laws. Failure to comply may result in civil money penalties (CMP) in accordance with the new provision section 1128 A(a)(5) of the Health Insurance Portability and Accountability Act of 1996 [section 231(h) of HIPAA]. Exceptional cases do apply. Office of Inspector General, Department of Health and Human Services. Phone: (202)619-1343, FAX: (202)260-8512, Email: paffairs@oig.hhs.gov, Mail: Office of Inspector General, Office of Public Affairs, Department of Health and Human Services, Room 5541 Cohen Building, 333 Independence Avenue, S.W., Washington, D.C. 20201


Children requiring supervision are NOT allowed to attend sessions with you.


Minors and Parents
If patient is a minor (under 18 years of age), the parent or legal guardian is responsible for all charges and decisions made by the minor. We do not assume any liability for the minor while on premises or not, and it is the responsibility of the parent or guardian to supervise the minor before, during and after treatments.

Informed Consent
When signing this form in-house, the patient gives the therapist permission to the evaluation and treatment. It is your right to accept or refuse any treatment offered. There are no guarantees made as to the results that may be obtained from our treatment(s). If you have any questions about your care, be sure to ask the therapist.

It is up to patient/caretaker to inform the therapist/staff about any health problems or allergies patient may have. Patient/caretaker must also tell the therapist/staff about drugs or medications being taken as well as any medical conditions and/or surgeries.

Please discuss any questions or problems with the therapist before signing this statement of understanding and consent for care.

Statement of Privacy Notice for Patients
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations.

We may disclose your health information to your insurance provider for the purpose of payment or health care operations.

We may disclose your health information as necessary to comply with State Workers’ Compensation Laws.

We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.

As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.

We may disclose your health information in the course of any administrative or judicial proceeding.

We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.

We may disclose your health information to coroners or medical examiners.

We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.

We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board.

It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.

We may disclose your health information for military, national security, prisoner and government benefits purposes.

We may leave a message on an automated answering device or person answering the phone for the purposes of scheduling appointments. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment.”

We may contact you by phone, mail, or email. “It is our practice to participate in charitable and marketing events to raise awareness, food donations, gifts, money, etc. During these times, we may send you a letter, post card, invitation or call your home to invite you to participate in the charitable activity.

In the event that we are sold or merged with another organization, your health information/record will become the property of the new owner.

You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that we are not required to agree to the restriction that you requested.

You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.

You have the right to inspect and copy your health information.

You have a right to request that we amend your protected health information. Please be advised, however, that we are not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.

You have a right to receive an accounting of disclosures of your protected health information made by us.

You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.

We reserve the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, we are required by law to comply with this Notice.

We are required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact us by calling this office at (480) 550-9100. If our Privacy Officer is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

Complaints about your Privacy rights, or how we have handled your health information should be directed to our Privacy Officer by calling this office at (480) 550-9100. If our Privacy Officer is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

DHHS, Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201

Medical Disclaimer
The information on this website is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images and information, contained on or available through this website is for general information purposes only.  Mission Physical Therapy makes no representation and assumes no responsibility for the accuracy of information on or available through this website, and such information is subject to change without notice. You are encouraged to perform additional research regarding any information contained on available through this website with other sources, and consult with your physician.

The information provided through this website should not be used for diagnosing or treating a health problem or disease. It is not a substitute for professional care. If you have or suspect you may have a medical or psychological condition, you should consult your appropriate health care provider. Never disregard professional medical advice or delay seeking care because of something you read on this website.

Mission Physical Therapy does not recommend, endorse or make any representation about the efficacy, appropriateness or suitability of any specific tests, products, procedures, treatments, services, opinions, health care providers or other information that may be contained on or available through this website.

MISSION PHYSICAL THERAPY IS NOT RESPONSIBLE NOR LIABLE FOR ANY ADVICE, COURSE OF TREATMENT, DIAGNOSIS OR ANY OTHER INFORMATION, SERVICES OR PRODUCTS THAT YOU OBTAIN THROUGH THIS WEBSITE.

Our mission is YOU. What is YOUR mission?

3321 E Queen Creek Rd #106 Gilbert, AZ 85297

on the SouthEast corner of Higley and Queen Creek Rd

by the Nook and Dairy Queen

Patient Rights
Each patient will be required to review their privacy rights and informed consent and sign to indicate they have done so. Minors needing treatment will need the permission and supervision of a parent or guardian.  According to policies and procedures, an evaluation of each patient is conducted before a transfer to another healthcare provider or facility with all treatment documentation, and the risks and benefits of the transfer is explained by a personnel member.  At the time of admission, each patient or the patient’s representative receives a written copy of the privacy rights.

Coercion, manipulation, sexual abuse, sexual assault, seclusion, and restraint (except when necessary to prevent imminent harm to self or others) is not tolerated.  Patients will not be subject to abuse, neglect, exploitation, retaliation for submitting a complaint to the Department or another entity, or misappropriation of personal and private property by personnel, employees, volunteers, students, patients, or representatives of patients of Mission Physical Therapy.  All patients will be treated with dignity, respect, and consideration.

Patients may either consent to or refuse treatment before treatment is initiated or anytime thereafter.
Patients will be informed of Mission Physical Therapy’s policy on health care directives and the patient complaint process.
Patients must give consent for photographs taken before a patient is photographed except that a patient may be photographed when admitted to an outpatient treatment
center for identification and administrative purposes.
Except as otherwise permitted by law, patients must provide written consent for the release of the patient’s medical records and financial records.
Patients will not to be discriminated against based on race, national origin, religion, gender, sexual orientation, age, disability, marital status, or diagnosis.
Patients are to receive treatment that supports and respects the patient’s individuality, choices, strengths, and abilities.
Patients are to receive privacy in treatment and care for personal needs;
Patients are permitted to review, upon written request, the patient’s own medical record.
Patients are to receive a referral to another health care institution if the outpatient treatment center is unable to provide physical health services for the patient.
Patients must participate or have the patient's representative participate in the development of, or decisions concerning treatment.
Patients may elect to participate or refuse to participate in research or experimental treatment.
Patients may receive assistance from a family member, representative, or other individual in understanding, protecting, or exercising the patient’s rights.

Interpreting services will be provided for those who are hearing impaired.  Those patients who do not speak English will need to bring their own interpreter to appointments.

Patient Abuse, Neglect, or Exploitation
If abuse, neglect, or exploitation of a patient is alleged or suspected to have occurred before the patient came to be under our care or while the patient is not on the premises and not receiving services from an employee of Mission Physical Therapy, the owner or a manager will immediately report the alleged or suspected abuse, neglect, or exploitation of the patient as follows:

For a patient 18 years of age or older, according to A.R.S. § 46-454, to a peace officer or to a protective services worker made immediately in person or by telephone and shall be followed by a written report mailed or delivered within 48 hours or on the next working day if the 48 hours expire on a weekend or holiday.  Reports shall contain:

The names and addresses of the adult and any persons having control or custody of the adult, if known.
The adult's age and the nature and extent of the adult's vulnerability.
The nature and extent of the adult's injuries or physical neglect or of the exploitation of the adult's property.
Any other information that the person reporting believes might be helpful in establishing the cause of the adult's injuries or physical neglect or of the exploitation of the adult's property.

For a patient under 18 years of age, according to A.R.S. § 13-3620, to a peace officer or to child protective services in the department of economic security, except if the report concerns a person who does not have care, custody or control of the minor, the report shall be made to a peace officer only.  Reports shall contain the following information, if known:

The names and addresses of the minor and the minor's parents or the person or persons having custody of the minor.
The minor's age and the nature and extent of the minor's abuse, child abuse, physical injury or neglect, including any evidence of previous abuse, child abuse, physical injury or neglect.
Any other information that the person believes might be helpful in establishing the cause of the abuse, child abuse, physical injury or neglect. 

The owner or manager will document the action and the report, and maintain the documentation for 12 months after the date of the report.

If abuse, neglect, or exploitation of a patient is alleged or suspected to have occurred on the premises or while the patient receiving services from an outpatient treatment center’s employee or personnel member, the administrator shall take immediate action to stop the alleged or suspected abuse, neglect, or exploitation; and immediately report the alleged or suspected abuse, neglect, or exploitation of the patient as follows:

For a patient 18 years of age or older, according to A.R.S. § 46-454 (see above),
For a patient 18 years of age, according to A.R.S. § 13-3620 (see above)

The administrator will investigate the suspected or alleged abuse, neglect, or exploitation and develop a written report of the investigation within 48 hours after the report required above that includes:

Dates, times, and description of the alleged or suspected abuse, neglect, or exploitation;
Description of any injury to the patient and any change to the patient's physical, cognitive, functional, or emotional condition;
Names of witnesses to the alleged or suspected abuse, neglect, or exploitation; and
Actions taken by the administrator to prevent the alleged or suspected abuse, neglect, or exploitation from occurring in the future;

The administrator will then submit a copy of the investigation report required in subsection to the Department within 10 working days after submitting the report in subsection; and maintain a copy for 12 months.