NOTICE OF PRIVACY PRACTICES 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION. PLEASE REVIEW CAREFULLY: 

I am required by the State of Washington to provide confidentiality for all medical/health records and other individually identifiable health information in my possession. This Notice is to inform you of the uses and disclosures of confidential information that may be made by Meld PT, and of your individual rights and Meld PT’S legal duties with respect to confidential information. 

Ways in which I may use and disclose your protected Health information: 

I may use and disclose at my discretion your medical records for each of the following purposes only: treatment, payment, and health care operations. 

● Treatment means providing, coordinating, or managing health care and related services. 

● Payment means activities, such as obtaining payment for the health care services I provide for you, from your insurance or another third party payer. 

● Health care operations include the business aspects of running a practice. 

I may contact you to provide appointment reminders or other services that may be of interest to you. I will disclose your protected health information to any person you identify that is involved in payment for your care. 

I will use and disclose your protected health information when required by federal, state or local law. There are certain situations in which as a therapist I am required by ethical standards to reveal information obtained during therapy to persons or agencies even if you do not give permission. These situations are as follows: (a) If you threaten grave bodily harm or death to yourself or another person, I am required by ethical standards to inform the intended victim and/or appropriate law enforcement agencies; (b) if you report to me your knowledge of physical or sexual abuse of a minor child or of an elder (over 65) or any sexual conduct/contact with a minor, I am required by law to inform the appropriate child welfare or social agency which may then investigate the matter; (c) if I am required by a court of law (court order) to turn over records to the court or if I am ordered to testify regarding those records. 

Any other uses and disclosures will be made only with your written authorization. You will be provided with an authorization form upon request. A separate form will be needed for each request for release of information. The authorization for release of records is valid until it expires or is revoked. You may revoke authorization in writing, and I am required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. 

Please sign to indicate you understand my operational use of your information for treatment, payment and health care operations as stated above.

PAYMENT POLICY

 Meld PT, PLLC is a fee-for-service clinic. We collect payment at the time of service. 

We do not bill insurance directly. If you have out of network (OON) benefits through your insurance company, you may submit a claim which may be eligible for reimbursement. Please request a Super bill in writing (via intake form). 

You are responsible for calling your insurance company to inquire about OON benefits and to see if a physician’s referral or pre-authorization are required. 

Due to Medicare’s rules, you cannot submit OON claims to Medicare. 

Prices are as follows: 

Physical Therapy Services:

Evaluation session:  $200.00 (55-60min session) 

Treatment session: $180.00 (55-60min session) 

Coaching Services: 

  • In person coaching sessions + training plan: $130.00 (55-60min in person) 

  • Virtual / phone consultations: $100.00 (up to 30min + training plan provided) 

Multisession (pre-paid) Packages, non-refundable: 

  • 4 sessions: $680.00 ($170.00 / 55-60min session) 

  • 6 sessions: $1,020.00 ($170.00 / 55-60min session) 

  • 12 sessions: $1980.00 ($165.00 / 55-60min session) 

Payments are accepted  by cash, check, credit, debit, or HSA/FSA cards (via Square). Returned checks will incur a $50 charge. 

*I have reviewed the clinic fees and understand that I am responsible for payment at the time of service. I understand I am responsible for contacting my insurance company in advance regarding OON benefits, pre-authorization, referrals, and claims. I understand I cannot submit for reimbursement to Medicare.

CANCELLATION POLICY 

Cancellations: We require a minimum of 24 hours notice for all cancellations. We appreciate knowing sooner if possible. This allows us to fill your appointment slot with another patient/client in need. We keep a running wait list. Please be respectful of this policy. 

You may cancel via phone or email.

Late starts: If you are going to be late for your appointment, please call, text, or email our office to notify us of your expected start time.  Your session begins at the appointment start time and will end after 55 minutes.   

1st late cancel: $100 due 

Subsequent late cancels: $125 due 

No show: full amount due 

Late arrival >30 minutes: full amount due and appointment forfeited 

Extenuating circumstances will be considered on a case-by-case basis; please contact by email. Patients are responsible for knowing when their appointments are scheduled. Although our scheduling system sends reminders, please do not rely solely on this system as it does occasionally experience errors. Note that if late cancellations or late arrivals become a chronic occurrence, we reserve the right to cancel upcoming appointments and offer them to other patients in need.

COVID-19 and Sickness Policy

In accordance with CDC and Washington State Dept of Health, masks are required in all healthcare facilities regardless of vaccination status. As Meld PT meets in various locations, masks are recommended. Your therapist will be masked.  We can meet and greet outdoors without masks for a short period prior to and at the end of any session. However, physical distancing is not possible for much of what I provide as a doctor of physical therapy.

You will not be charged a late cancellation or no-show fee for close contact exposure, illness, or signs/symptoms consistent with COVID-19. If you have been in contact with someonewho tested positive, for more than 15 min over a 24-hour period,  please reschedule.

Please be aware of the following signs/symptoms consistent with COVID-19

  • Fever

  • Cough

  • Headache

  • Loss of taste or smell

  • Difficulty breathing

  • Extreme fatigue (normal tasks such as ascending stairs is extremely labored)

We will reschedule for 10 days after onset of symptoms and at least 24 hours after your last negative COVID-19 test.