FORMS

Please begin by reading through the Appointment Information tab below.

Then click on each tab to print out the required form, fill out the forms, and bring them to your first appointment.

If there are any problems accessing the forms, please contact: bob@carboncreekpt.com or (970) 901-7684.

Patient Forms

Appointment Information

Appointment Information

Welcome to Carbon Creek Physical Therapy, LLC!

Below is important information you will need regarding your upcoming appointment. Please call or email if you have any questions prior to your appointment.

  • Intake Forms: The client intake forms will help me to serve you better – there are six (6) forms. Each form supplies important background information about you.  Injuries or illnesses that may seem, to you, to be unrelated to your current symptoms may be very important for me to know.   Please print each form, read, complete, and bring each form to your appointment.Rates/Payments: The initial evaluation and assessment is sixty (60) minutes long. The standard rate is $145.00 for this initial evaluation/treatment.  Subsequent visits are 50 to 55 minutes long.  The standard rate for follow-up visits is $120.00. Payment is due at the time of service, in the form of cash or check (preferred method of payment).  Please make checks out to: Carbon Creek Physical Therapy LLC.
    • Invoices/Insurance: With the exception of Medicare, Carbon Creek Physical Therapy, LLC does not bill insurance. We will provide invoices, upon request, which you can submit for reimbursement to your insurance provider.  Most insurance providers will reimburse you for your treatment, typically at an “out-of-network” rate.  Please inform me at your appointment if you would like an invoice.  Carbon Creek Physical Therapy LLC is considered Out-of-Network, Outpatient Physical Therapy.
    • Clothing: Please wear loose and comfortable clothing that will allow us to examine the areas of concern. (Shorts, workout pants, sports bra, tank top…).
    • Location: Carbon Creek Physical Therapy, LLC is located 121 W. Virginia Street, Suite A (next door to Gunnison Shipping). There is a waiting area just inside the main door to the left as you enter, outside of the treatment room – please make yourself comfortable!  If I am treating the previous client, please have a seat and I will come out to get you at your appointment time.  I strive very hard to run on time, however there may be instances where I am running late due to unexpected needs of the client in the office.  Thank you in advance for your patience!
      • Cancellation Policy: Please carefully review our cancellation policy on the Consent to Treat

 

Thank you! I look forward to working with you.

Bob Baumgarten, MS, PT, CFMT, FAAOMPT

Notice of Privacy Practice

 Read below or print out: NOTICE OF PRIVACY PRACTICE

NOTICE OF PRIVACY PRACTICE

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOUR HEALTHCARE INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our Policy on Medical Record Privacy

This notice will describe the way our practice will treat the medical records we keep regarding your medical care. We are required to keep a record for you care, including your diagnosis, treatment, services you receive, and other information. We are required by law to protect your personal medical record by keeping it private and following certain rules that dictate whether and when we can use or disclose your information. This notice will inform you of these rules. It will also notify you of your rights and our obligations in our use and disclosure of your health information. We are also required to give you notice, and to follow the terms of the notice that is currently in effect. We reserve the right to change this notice, and apply those changes to health information we currently have, as well as information we may receive in the future. If we change this notice, you will receive a new copy of this notice the next time you receive services from our practice. A copy of this notice will be on display in our office.

Understanding Your Health Record

Each time you visit Carbon Creek Physical Therapy, LLC, a record of your visit is made. Typically, this record contains your symptoms, examination, test results, diagnosis, treatment, and a plan for future care of treatment. This information, often referred to as your health or medical record, may serve as a:

      • Basis for planning your care and treatment
      • A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve
      • Means of communication among the many health professionals who contribute to your care
      • Legal document describing the care you received
      • Means by which you or a third party payer (such as your insurance company or HMO) can verify that services billed were actually provided
      • A source of data for medical research
      • A source of information for public health officials charged with improving the health of Colorado and the nation
      • A source of data for planning and marketing

Your Rights Regarding Your Health Information

You have the right to:

      • Request that we restrict the use or disclosure of your health information for treatment, payment, or healthcare operations (as described in this notice)
      • Request that we restrict from disclosing information to family or friends
      • Request how you would like us to communicate with you
      • Inspect and copy certain health information, including most of your medical and billing records. This request must be made in writing to the Privacy Officer. A reasonable fee may be applied for copying, postage, or other expenses related to your request. We may deny your request to inspect and or copy your health information. If we do, another licensed health care professional will review your request and we will comply with the outcome of the review.
      • Amend your health record as provided in 45 CFR 164,528
      • Obtain an accounting of disclosure of your health information as provided in 45 CFR 164,528
      • Obtain a paper copy of this notice upon request

NOTE: We are not required to agree to your requests. To request restrictions or limitations, you must make a written request to Carbon Creek Physical Therapy, LLC. The request must tell us (1) what information you want to limit; (2) whether you want to limit the use of the information and or disclosure of the information; (3) to whom the limitation or restrictions will apply.

Our Responsibilities

Carbon Creek Physical Therapy, LLC is required to:

      • Maintain the privacy of your health information
      • Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
      • Abide by the terms of this notice
      • Notify you if we were unable to agree to a requested restriction
      • Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact the Carbon Creek Physical Therapy at 970-901-7684.

If you believe your privacy rights have been violated, you can file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filling a complaint. The address for the OCR is listed below:

Office for Civil Rights
U.S. Department of Health and Human Rights 200 Independence Avenue, S.W.

Room 509F, HHH Building
Washington, D.C. 20201

How We May Use and Disclose Your Health Information

We may use and disclose your health information for a number of purposes in connection with your medical care and in running our practice. The following lists a number of typical uses and disclosure within our practice. You will not be asked to separately authorize us to do these things. We will use your health information for the following:

Treatment

We may use your health information to diagnose your illness or injury, provided you with services, or refer you to another physician. We may disclose your health information to doctors, nurses, technicians, medical students, or other personnel who are involved in your care. We also may disclose your health information to people outside of our medical practice who may be involved in medical care, such as family members, clergy or others.

Payment

We may give your health plan information regarding you diagnosis and treatment in order to be paid for your office visits, procedures, x-rays, or laboratory work. We may also provide information to determine whether your health plan pays for medical care you need, and whether we need to get authorization from the health plan before treating you.

Health Care Operations

We may use or disclose your information if we conduct quality assessment and improvement activities to ensure that our patients receive quality medical care. We may also use or disclose your information in training and evaluation of our physicians and other staff, or as part of a medical review, audit, or legal activities.

Appointment Reminders

We may use or disclose your information to contact you as a reminder that you have an appointment with our practice. 

Individuals Involved in Your Care or Payment for Your Care

We may disclose your health information to a family member or friend who is involved in your medical care or who helps pay for your care. We may also tell your family or friends about your condition, for example, if you are admitted to the hospital or in the event of a disaster relief effort.

Public Health Risk

We may disclose your health information to report disease, injury or disability; births and deaths; child or elder abuse or neglect; defects, recalls or problems with drugs, medical devices, or other products; to prevent or conditions. We may also notify authorities if we believe you have been the victim of abuse, neglect or domestic violence, if we are required by law to do so, or if you agree to the notification.

Health Oversight Activities

We may also disclose your health information to agencies authorized by law for audits, investigations, inspections, and licensure.

Law Enforcement

We may disclose your health information when the following circumstances apply:

If you have incurred certain injuries or wounds that are legally required to be reported;

In response to a court order, subpoena, warrant, summons, Investigative demands, or similar process;

To identify or locate a suspect, fugitive, material witness, or missing person; About the victim of a crime if under certain limited circumstances;

About a suspicious death that we believe may be the result of criminal conduct;

About criminal conduct on our premise;

In emergency circumstances to report a crime, its location, or information about the person who may have committed the crime.

Coroners, Medical Examiners, and Funeral Directors

As necessary to carry out their duties.

Specialized Government Functions

We may disclose your health information to release information to military command authorities, upon you separation or discharge from military service to authorized officials. We may also disclose your health information to the appropriate government officials when it is necessary to conduct intelligence or other national security activities authorized by federal law. In addition, we may release your health information if it relates to the protection of the Presidents of the United States or foreign heads of state. Finally, we may disclose certain information related to members of the armed services and foreign military services to the appropriate personnel.

Inmates

If you are an inmate of a correctional facility or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official in order to provide you with medical services, protect you or others, or to ensure safety of the correctional facility.

Workers’ Compensation for Work Related Illness or Injuries

We may disclose your health information in relation to workers’ compensation or similar programs established by law that provides benefits for work-related illness or injuries.

Other Uses of Your Health Information

We may disclose your health information when required by federal, state or local law, for treatment alternatives or health related benefits/services, organ and tissue donations, or to avert a serious threat to health or safety.

 

 

 

© 2020 - Carbon Creek Physical Therapy
Graphics by Beth Marcue, Marcue Designs, https://www.bethmarcue.com/.
Carbon Peak Photos by Robert Valdez.