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Intake forms
Please complete the six intake forms below and email them to me the day before your appointment at the latest. All patients are kindly asked to email me or bring along any results of pertinent tests such as x-rays, MRIs, CT scans, blood work etc, to your first appointment.
You may also choose to arrive 15 minutes early in order to fill out forms before your initial evaluation. Please notify me via email if you would like choose this option.
Please complete the six intake forms below and email them to me the day before your appointment at the latest. All patients are kindly asked to email me or bring along any results of pertinent tests such as x-rays, MRIs, CT scans, blood work etc, to your first appointment.
You may also choose to arrive 15 minutes early in order to fill out forms before your initial evaluation. Please notify me via email if you would like choose this option.
Fill out and email me all the forms below before your first appointment :
MEDICAL SCREENING QUESTIONNAIRE INFORMED CONSENT
DEMOGRAPHIC INFORMATION NOTICE OF PRIVACY PRACTICES
PAYMENT AND CANCELLATION POLICY CREDIT CARD AUTHORIZATION
Click on each document listed above, download it, fill it out and email the documents at least a day before your first appointment.
Note: You do not need to submit all three pages of the Notice of Privacy Practices document, only the signature page. If you are scheduled for an online consultation, only the medical screening questionnaire is recommended.
DEMOGRAPHIC INFORMATION NOTICE OF PRIVACY PRACTICES
PAYMENT AND CANCELLATION POLICY CREDIT CARD AUTHORIZATION
Click on each document listed above, download it, fill it out and email the documents at least a day before your first appointment.
Note: You do not need to submit all three pages of the Notice of Privacy Practices document, only the signature page. If you are scheduled for an online consultation, only the medical screening questionnaire is recommended.
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INSTRUCTIONS FOR SCHEDULING APPOINTMENTS Click the "Schedule Appointment" button above to schedule, then create an account using your full name and use that same account every time you schedule an appointment. Do not choose the option to "skip the login process"! You do not need a referral for physical therapy. However, Medicare beneficiaries need to have their treatment plan signed by a MD or DO within a month of the initial appointment, so please be ready to give the name, credentials and contact information (fax number) of your medical provider. |
If you need to cancel an appointment, please do so as soon as possible. Please be considerate and do not wait until right before the cancellation window (24 hrs), as cancellations this close to the appointment time are hard to fill. Out of respect for your fellow patients and your therapist, cancel early in order to give other patients an opportunity to book the appointment slot. Cancellation policy: appointments must be cancelled 24 hours before the scheduled appointment time. Late cancellations and no-shows, no matter what the reason for them, will lead to a $155 (the cost of the appointment) cancellation fee. Agreeing to the cancellation policy is a prerequisite for scheduling an appointment. Questions about the cancellation policy? Read more here . |
Additional Information
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LOCATION:
The physical office is located at 1570 Oak Avenue, Ste 101, Evanston, IL 60201 - Door code #101 TELEHEALTH SESSIONS: Delivered via https://doxy.me/lilianholmwellness on your computer or mobile phone. CONTACT INFO: Phone: (847) 208-8063 (please text only during business hours, use email outside of business hours) Fax: (847) 492-0321 Email: lilianholmpt@gmail.com or click here to contact me via email. Please note: You will typically receive a faster response to e-mail than phone/voicemail. AVAILABLE HOURS Additional appointment times may occasionally be available by request. Email to inquire about a specific time. MY MEDICAL DOCTOR HAS RECOMMENDED PHYSICAL THERAPY. DO I HAVE A CHOICE IN PROVIDERS? Yes, regardless of who the referring physician is, you do have the right to be seen by any physical therapist you like, and unless you have an HMO insurance, your insurance policy covers physical therapy anywhere. You are encouraged to explore your options, and you will find that Lilian Holm Wellness offers something unique: a full hour one on one with your physical therapist, and email access to your therapist outside of your appointments. PAYMENT FOR SERVICES - FAQ Physical Therapy is covered by health insurance. I accept and am an in-network provider for Blue Cross/Blue Shield PPO and Medicare (Medicare HMO plans are not accepted). Tricare, Worker's Compensation Insurance claims and Auto Insurance claims are also accepted. Call your insurance provider prior to scheduling a Telehealth appointment to make sure that it will be covered. Charges for in-network patients are submitted directly to insurance. Please be aware that deductibles are due at the time of service for clients seen in-network. Clients covered under an out-of-network insurance policy will receive an itemized receipt that they simply submit to their insurance company for reimbursement. Please understand however that Lilian Holm Wellness does not assume any responsibility for how your insurance company handles the charges. Health and Wellness coaching is not covered by insurance. I HAVE NON-BCBS INSURANCE. WHY GO OUT OF NETWORK? You should see an out-of-network practitioner when it's in your best interest. Reimbursement rates for in-network practitioners for many policies are so low that only clinics that only clinics that double-book patients, and/or delegate the treatment to assistants and aides, can remain in network with them. You may still benefit from, and need, other forms of care, such as manual orthopedic therapy, or prefer to be treated by a Doctor of Physical Therapy instead of a less qualified professional, and therefore benefit from going out-of-network. Remember that out-of-network services may be covered at almost the same rate as in-network services, once your deductible has been met, but you will actually be getting what you pay for; the full attention and care of a physical therapist. WHY IS THERE NO OFFICE STAFF? The practice model for Lilian Holm Wellness is based on a niche service of individualized one-on-one care. Only by eliminating the cost of support staff is it possible to provide one-on-one care while accepting insurance and keeping self-pay fees affordable. This means that if you call during business hours you may leave a voice mail. Communicating via email is strongly encouraged, as it helps us to get in touch faster. If you need to get in touch immediately during business hours, e.g. because you are running late, you are welcome to text. |
COST
When using Medicare or Blue Cross Blue Shield the insurance company sets the price and the patient is only responsible for the deductible and the copay, if applicable. Self-pay in-office and self-pay Telehealth fees are as follows: The cost of the initial evaluation is $175 (70 minutes) Subsequent visits are $155 (70 minutes). Physical therapy Consultations (70 minutes): $175 Extended Physical Therapy Consultations (2 hrs 20 minutes) $320 Aetna, Cigna, United Healthcare (non-medicare plans) etc policy holders are seen for physical therapy on a self-pay basis, and may submit their superbill (a detailed bill containing all pertinent codes required for reimbursement) to their insurance company for reimbursement as applicable. Please note that all patients are required to keep a valid credit card on file! APPOINTMENT TYPES PHYSICAL THERAPY EVALUATION Initial in-person appointment for physical therapy patients. All other therapy appointments for new or returning patients must be preceded by this appointment type. The purpose of the evaluation is to understand your medical history, your current symptoms, goals for treatment, perform a thorough evaluation and create a treatment plan. Time permitting, this appointment also contains an initial treatment and home exercise prescription. Please download the HIPAA compliant home exercise app AC Health (access code: 989) prior to your evaluation. Choose either the insurance pay option or the self-pay option. PHYSICAL THERAPY FOLLOW-UP APPOINTMENT All subsequent physical therapy in-person appointments are scheduled as follow-up. PHYSICAL THERAPY TELEHEALTH APPOINTMENT Telehealth (video) appointments, for both individuals using insurance or self-pay patients. Please choose between in-person or Telehealth when scheduling. For patients using insurance choose Telehealth Physical Therapy Session - BCBS or Medicare - Initial evaluation or follow-up. Self-pay patients choose Telehealth Physical Therapy self-pay evaluation for the initial appointment, and Telehealth Physical Therapy Session for Self-Pay patients for subsequent appointments. CONSULTATIONS Educational video consultation, intended for individuals with hypermobility disorders (EDS/HSD) wishing to better understand the concerns and options related to these conditions. Consultations can also be used to connect me to your local physical therapist to guide them through general information about hypermobility conditions to help them adapt treatment to be more appropriate for these disorders. Consultation appointments cannot be used to diagnose or treat individual conditions. Please note: In-person appointments are scheduled as Physical Therapy Evaluation Choose either: Physical Therapist Consultation - US and International (70 min) or Extended Physical Therapist Consultation - US and International (2 hrs 20 minutes) HEALTH COACHING Health coaching are educational appointments, where the client chooses the topic(s) among any aspect of health-related topics. Health coaching appointments are self-pay appointments. REFERRALS The State of Illinois has direct access to physical therapy, which means that you do not need a referral from a physician or other provider in order to have physical therapy. Medicare requires that your treatment plan be signed by your physician. This simply means that your treatment plan will be faxed to your physician of choice directly from our office. If you prefer, you can also ask your physician to fax a referral directly to me at 847-492-0321. You do not need a prescription for Consultations and Health and Wellness Coaching. CANCELLATIONS OF PRE-PAID APPOINTMENTS The fee charged for pre-paid appointments will be refunded upon request (please note that this is not an automatic process) minus the fee collected for the transactions by Square. If you wish to reschedule a prepaid appointment, please contact me directly using the form at the top of the page. DO I NEED TO HAVE PAIN OR AN INJURY TO HAVE PT? Physical Therapy is a way of taking care of your body, and just like your car or home it needs some maintenance. You don't need to - and arguably shouldn't- wait to be ill before you start taking care of your body. Regular Physical Therapy checkups are just as good an idea as regular checkups with your dentist or physician. CANCELLATION POLICY Appointments must be cancelled at least 24 business hrs in advance. Late cancellations and no-shows lead to a $155 fee per cancelled hour, payable before the next appointment. However, when possible, earlier cancellations are much appreciated and increase the chances of another client on the waiting list being able to be seen. Please be considerate of the need of your fellow patients to be seen and cancel as early as possibly if you can't make your appointment. WHY IS THERE A CANCELLATION POLICY? Clinics guard against the financial loss that last-minute cancellations and no-shows present through a variety of measures, such as over-booking or double-booking clients. Because of this, most clinics do not offer one on one services, but require that the physical therapist treat several patients simultaneously. Hour-long one-on-one services are not possible under such an arrangement. Lilian Holm Wellness is based on a model of personalized care with manual physical therapy and individualized coaching at the core of the PT services. With this type of practice it is not possible to double-book patients. This makes a cancellation policy a necessity. Agreeing to this policy is a prerequisite for receiving the services, and all patients sign a binding form detailing the cancellation policy before therapy is initiated. Cancellation policies exist to keep the practitioner in business so that s/he can continue to serve you. As such, it is not affected by extenuating circumstances, and the cancellation policy is always in effect, regardless of what the reason for the cancellation is. A agreeing to the cancellation policy as outlined and signed is a prerequisite for receiving the services of Lilian Holm Wellness. Any exemptions would be unfair to all other patients bound by the very same policy and render the business model as described impossible. |