individualized disclosure statement · welcome to the origami brain injury rehabilitation...

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Individualized Disclosure Statement

Client Name: ___________________________________ Date of Admission: _____________

Welcome to the Origami Brain Injury Rehabilitation Center’s _____________________Program!

Upon admission you will receive the following services*:

Professional Services Frequency Specialty Services Frequency

Behavior Analysis hours per week Animal Assisted Therapy hours per week

Care Coordination As needed Aquatic Therapy hours per week

Dietician hours per month Concussion Care hours per week

Nursing Services hours per week Cognitive Perceptual Motor Retraining hours per week

Occupational Therapy hours per week Driver Rehabilitation hours per week

Physiatry hours per month LoveYourBrain Yoga hours per week

Physical Therapy hours per week Manual Therapy hours per week

Psychiatry hours per month Neuro-Visual Postural Training hours per week

Psychology hours per week Serial Casting hours per week

Therapeutic Recreation hours per week Vestibular Rehabilitation hours per week

Social Work hours per week Vision Therapy hours per week

Speech-Language Pathology hours per week

Vocational Services hours per week

*Services may be added or discontinued after initial evaluations are completed. You will be kept informed.

*Estimated Length of Service: In approximately four to six weeks, you will receive a rehabilitation summary report in which your length of stay

will be predicted and shared with you. On occasion, your length of stay may be known prior to the four weeks and will be discussed with you at

that time.

*Reference Financial Agreement for disclosure of financial responsibilities for services rendered.

*If alternative resources not provided at Origami are needed for your care, rehabilitation and recovery, Origami will work with you to identify

and access these resources in the community.

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Financial Agreement

Client Name (Printed): _____________________________________

I authorize Origami Brain Injury Rehabilitation Center, or their designated representatives, to pursue

payments from my insurance carrier for services rendered.

I authorize the release of any protected health information pertinent to my case to any insurance

company, adjuster, or attorney involved in this case, and, if necessary, the initiation of a complaint to the

Insurance Commissioner on my behalf.

I understand that if I have a policy with coordination of benefits, I may be required to submit the claims

to my primary insurance carrier. Origami will prepare the claim and give me any assistance that I may

require in submitting them.

I understand that I must take all reasonable measures to forward all information, payments, and/or

correspondence from all involved insurance companies relating to the service provided.

I understand it is my responsibility to provide Origami with a copy of my primary insurance card

immediately if changes occur. Changes with my primary health insurance may impact the secondary

insurance provider’s responsibility for payment.

I agree to give Origami a minimum of 14 day notice of my/our decision to discontinue this agreement and

agree to pay Origami for services rendered up until said notice date.

Except where prohibited by law or contract, I understand that I am personally responsible for any amount

not paid by my insurance carrier. This includes deductibles, co-pays, and co-insurances but also services

rendered by Origami, not covered by insurance. I understand I am responsible for all charges incurred

related to my care, recovery and rehabilitation. This includes services identified on my individualized

disclosure statement and any subsequent adjusted services and programs identified to meet my individual

needs. Origami will provide me with notice of recommended changes. Associated fees will be available

upon request prior to initiating any service. All payments are due within 30 days from receipt of invoice.

Failure to make payments as indicated may cause Origami to initiate discharge proceedings, if applicable.

I agree to provide at least 24-hour notice if unable to attend a scheduled therapy session/meeting. Failure

to provide 24-hour notice is considered a “no show”. More than 2 no shows for any scheduled date of

service, other than psychiatry, physiatry, and sessions in which the clinician had to travel into the

community, will result in being personally billed $50.00 for each day of service. All no shows for psychiatry,

physiatry, and sessions in which the clinician had to travel into the community will result in a $50.00

charge. I also understand that services may need to be placed on hold or discontinued until attendance

can be consistent and any payments for past no shows are remitted.

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I acknowledge and agree that Origami reserves the right to submit and collect its own charges. I further

acknowledge and agree that Origami reserves the right to make decisions regarding payment negotiation,

settlement, allowances, or disallowances with regard to its charges. In addition, I agree that Origami

reserves the right to hire its own attorney to represent its charges. Moreover, I agree to notify Origami of

any existing or forthcoming litigation regarding any of my claims for no-fault benefits.

Insurance:

Primary Insurance: Provider: Number:

Secondary Insurance: Provider: Number:

Special Arrangements:

Supplemental Document Attached

I certify the above information is correct and agree to pay Origami Brain Injury Rehabilitation Center as detailed above. This agreement covers all services provided by Origami whether in-office, in the community, and/or telehealth services. The check is to be made payable to Origami Brain Injury Rehabilitation Center for dates of services described on the bill.

Signed,

__________________________ ___________ _____________________________ ___________ Client Signature (required) Date Guardian Signature (if applicable) Date

__________________________ ___________ _____________________________ ___________ Origami Representative Date Guarantor Signature (if applicable) Date

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Release of Information

I. The information released in this authorization is confidential. Further disclosure of this information is prohibited unless otherwise permitted by Federal and State laws. II. Name: ______________________ Date of Birth: ____________ Today’s Date: ______________ III. I hereby authorize Origami to release and/or obtain written and verbal information under the conditions specified below:

1. Alcohol, drug abuse, and mental health treatment information protected under the regulations in Title 42 of the Code of Federal Regulations Part II.

2. Human Immunodeficiency Virus (HIV), Acquired Immunodeficiency Syndrome (AIDS) and AIDS Related Complex (ARC) information made confidential by Public Act 488 as amended by Public Act 174 of 1989 of the Michigan Health Code.

3. Hepatitis B, Venereal Disease, Tuberculosis and other communicable diseases, infections and serious infections made confidential in rules promulgated by the Michigan Department of Public Health pursuant to Public Act 174 of 1989 of the Michigan Health Code.

This authorization gives Origami the ability to discuss my medical care with and or receive records from any previous or future medical care providers, insurance companies or other persons relevant to my care. The information will be released to and/or obtained from persons involved in my rehabilitation services. Information to be released and/or obtained: (check all that apply) All of the below

ER Report History & Physical Discharge Summary Hearing/Vision Report Consultations MRI/CT Scan Reports Psychological Reports EEG & Evoked Potential Studies Neuropsych Reports Progress Reports Immunization Records Transportation Company School Records Progress Notes Employer Records Electronic Health Information CT Scans X-Rays Other:

IV. My signature indicates that I know what information is being released and any consequences that may arise as a result of my signing this authorization, or refusing to sign. I have read this form, or had it read to me and explained in language that I can understand. All the blank spaces have been filled out except for my signature and the dates. This consent may be revoked in writing at any time, except to the extent that action has been taken in reliance on it. Unless this consent has been revoked in writing, it will automatically expire upon one year from the date of the signature indicated below or on the date in which the client is discharged from Origami services.

Signed,


__________________________ ___________ Origami Representative Date

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Advance Directives Acknowledgement Form

I,____________________________, acknowledge I have received information on advance directives and do-not-resuscitate (DNR) declarations in the Origami Welcome Handbook. As of this date, , I do/do not have the following to provide for inclusion in my Origami medical record: Durable Power of Attorney: Yes No Enacted Durable Power of Attorney: Yes* No *Must have 2 signatures, one being made by your attending physician and confirmed by a second physician or licensed psychologist

Do-Not-Resuscitate Declaration: Yes No Patient Advocate Designation (PAD): Yes No A copy of your advance directives and DNR declaration should be kept by you, a family member, your personal physician, and Origami. These documents will be part of your Origami medical record. Your care providers at Origami will be alerted of your DNR status and, if you are to be transported to a hospital or encounter emergency responders on-site, your advance directives would be made available to them. It is the policy of Origami to make every effort to sustain the life of those in our care; therefore, if the circumstance presents itself, Origami employees will utilize their training to make efforts to resuscitate all individuals in need. If this policy causes you to determine that Origami is not the right place for your care and rehabilitation, we will assist you in locating appropriate alternative options. While at Origami, your wishes will be reviewed with you on an annual basis by your Care Coordinator unless you initiate the discussion sooner. You may, at any time, change or terminate your advance directives and DNR declaration. Your revised wishes will need to replace your previous advance directives and/or DNR declaration in your medical record. If your wishes change, they will be communicated with your care providers at Origami. Accidental Exposure of the Healthcare Worker: In the event that you may be harboring an infectious disease such as Hepatitis B, Human Immunodeficiency Disease (HIV), or other communicable disease which could endanger the health of individuals accidentally exposed to your blood or body fluids, your signature below gives consent to testing deemed necessary by your physician or his/her designee in the event of an accidental exposure to a healthcare worker. Such testing is necessary to protect those who

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will be caring for you. Any test results will become part of your medical record, and as such its confidentiality is protected by federal law. Signed, __________________________ ___________ _____________________________ ___________ Client Signature (required) Date Guardian Signature (if applicable) Date __________________________ ___________ Origami Representative Date

For Office Use: If client/guardian checked “Yes” regarding having a Durable Power of Attorney, PAD, and/or a DNR order, but did not have the document on hand upon admission, the following individual will be informed and will be responsible for following up to attempt to obtain these documents and include them in the client’s medical record. In addition, if the client was provided with a DNR order form, this person will be responsible for retrieving the form from the client, including it in the client’s medical record, and notifying employees of the exact order: ______________________________________ Care Coordinator

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Media Release

Client’s Name (Printed): ___________________________ I agree to my being photographed and or video/ audiotape during my participation at Origami. The photographing may be for clinical and/or administrative purposes. The video/audio taping may be initiated during therapy sessions for providing feedback and increasing awareness of my therapy goals. No one else will be the focus of the tape or photograph. I understand and agree that these images and recordings may be duplicated, distributed with or without charge, and/or altered in any manner without compensation or liability, in perpetuity. This authority extends to all conventional and electronic media, including the internet and any future media. I understand if I choose to participate in video conferencing it will be using an unsecured internet connection making the transmission of the discussion potentially exposed. I release Origami from liability and security of such transmission. I also understand that I have the right to refuse to be photographed or video/audio taped.

I hereby consent to being photographed and/or video/audio taped while participating in activities offered by Origami. In addition, I consent to the reproduction and use of any such photographs and videotapes by Origami for educational, public relations, and promotional purposes and I waive any claim by myself, or anyone claiming under or through me, for compensation of any kind in exchange for such photographs, and videotapes and use.

Agree Decline

I give permission for my name to be used in conjunction with these photographs or video/audio tapes. Agree Decline

I give permission for my photograph to be used for purposes of Origami’s internal electronic documentation systems. This photo is not visible to non-Origami employees and is used for the primary purpose of client identification.

Agree Decline

Signed,



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Treatment Consent Form

Client Name (Printed): _________________________________________

I consent to allow the providers of Origami Brain Injury Rehabilitation Center to perform necessary

assessments and treatments to address my health condition(s).

I have the right to have an Origami chaperone when I am with my provider if an advance verbal or written

request is made. I have the right to bring an external chaperone of my choice to join in any treatment

session.

I understand that clinical interns and/or observers may be involved in my treatment sessions and that I

have the right to refuse their involvement. Please check the below box with your preference.

I consent to interns and/or observers in treatment sessions

I do not consent to interns and/or observers in treatment sessions

My consent varies on the treatment and I would like each provider to ask prior to the treatment

session

For safety and security purposes, Origami has 24-hour surveillance cameras on campus and within

buildings. Cameras are located in treatment locations with blocked views (quiet room and neuro-visual

optometry office). Recorded footage is stored in a secured location with the sole purpose of the health

and safety of our clients and employees.

I have the right to discuss any treatment with my provider. I am encouraged to ask questions that I may

have.

This consent is valid until revoked in writing.

Signed,



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Treatment Consent Form for Minors

Client Name (Printed): _________________________________________

Client Date of Birth: _________________

I. Parents(s) and/or Legal Guardian(s):

_______________________________ ________________________ ___________________ Parent or Legal Guardian Name Phone number Relationship to Client

_______________________________ _________________________ ___________________ Parent or Legal Guardian Name Phone number Relationship to Client

II. Consent to Treatment

I, ___________________________________, parent or legal guardian of the client listed above, do hereby consent to allow the providers of Origami Brain Injury Rehabilitation Center to perform necessary assessments and treatments to address the health condition(s) of this client who is a minor.

By signing below, I attest that I have legal authority to consent to the medical treatment of the minor client listed above. I understand that if a dispute arises as to a parent’s authority to make decisions on behalf of the minor, a court order must be provided to Origami.

The client has the right to have an Origami chaperone when with a provider. Advance verbal or written request is preferred. The client has the right to bring an external chaperone of their choice to join in any treatment session.

I understand clinical interns and/or observers may be involved in treatment sessions and I have the right to refuse their involvement. My preference is selected below.

I consent to interns and/or observers in treatment sessions

I do not consent to interns and/or observers in treatment sessions

My consent varies on the treatment and I would like each provider to ask prior to the treatment session

I understand, for safety and security purposes, Origami has 24-hour surveillance cameras on campus and within buildings. Cameras are located in treatment locations with blocked views (quiet room and neuro-

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visual optometry office). Recorded footage is stored in a secured location with the sole purpose of the health and safety of Origami's clients and employees.

I have the right to discuss any treatment with my provider. I am encouraged to ask questions that I may have.

This consent is valid until revoked in writing or until the minor becomes of age to sign on his/her own behalf.

Signed,



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Acknowledgement of Forms Received Upon Admission

Client’s Name (Printed): __________________________________________ I acknowledge I have received a copy of the below listed admission forms. By signing below, I indicate understanding of the forms as listed below and consent to their respective provisions. I understand if I have any questions, concerns, or suggestions I am encouraged to ask my assigned Care Coordinator. Grievance Procedure Notice of Privacy Practices – HIPAA Client Rights Community Guidelines (including weapons and drugs/alcohol restriction/ban)

Acknowledgement of Random Room Searches & Cleaning (Residential and Community Based Programs only)

Signed, __________________________ ___________ _____________________________ ___________ Client Signature (required) Date Guardian Signature (if applicable) Date __________________________ ___________ Origami Representative Date

individualized disclosure statement · welcome to the origami brain injury rehabilitation...

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