• A medical history and intake form will be sent through the client portal of a secure electronic medical record.

• Please complete this fully and if possible 48 hours prior to your first session, to prepare for your evaluation.

• As an independent practice, we do not have access to your doctor, hospital or healthcare system’s medical records.

• We rely on the information you supply to inform your care.

Private practitioners have the autonomy to deliver services customized to your needs.

You will receive expert care from a seasoned professional with advanced specialty training for a broad range of solutions for your needs.

Individual sessions will always be delivered.

Our environment allows for the calmness needed for restoration.

You will be treated with personalized care that puts you first. We honor your time, your goals and your journey.

• Katherine Jackson Occupational Therapy, PLLC is in network with BCBS PPO, BlueChoice and Traditional Medicare.

• If you have other insurance, contact your provider to determine whether your plan reimburses for out of network services.

• If you are eligible for out of network benefits, inquire about your co-insurance responsibility.

• Cash payment is expected from clients who intend to use out-of-network benefits.

• We provide what is commonly known as a “superbill,” or a document you can use to submit an insurance claim and request reimbursement for cash fees paid.

I work out of a private Physical Therapy and Pilates Wellness studio called Collective Motion in northwest Evanston. We are located on the corner of Central St and Hurd Ave, with the entrance to the ground-floor studio on Hurd.

• Street parking is available with no meters on Hurd Ave.

• Central street has metered parking.

• There is a curb cut at the alley on the south end of the building.

• Per Illinois state law, an MD prescription is no longer required for an occupational therapy evaluation.

• A signed plan of care from a physician or non-physician practitioner is required prior to initiating treatment.

• Acceptable signatures come from your: MD (Medical Doctor,) DO (Doctor of Osteopathic Medicine,) Nurse Practitioner (NP,) Clinical Nurse Specialist (CNS,) or Physician Assistant (PA)

• Some insurance providers require a prescription for coverage of services.

• It is in your best interest to have a prescription for OT. The prescription ensures that your provider will be willing to sign your plan of care for OT. Your prescription also maximizes your access to insurance reimbursement.

As a small office, we ask that you consider our time and the time of others seeking care. We also understand that life throws curveballs, not always allowing for advanced notice.

• Please give 24 hours notice for cancellations.

• Call/text us at (847) 238-2008

• Late cancellations and missed appointments may be subject to a $50 fee.

• This fee is not covered by insurance and will be charged to the credit card on file.

HIPAA compliant systems are utilized for communication.

Your client portal will allow access to a secure direct messaging system.

Email allows for a quick response time.

Detailed text messaging via mobile phone is not encouraged due to lack of privacy protection, replies via text will be brief to protect your health information.

• Estimated deductible payments, co-payments, and self-pay payments are due at the time of service.

• We accept cash, Zelle, Venmo, checks, or credit cards.

• Health Saving Account (HSA) funds may be used to pay for occupational therapy services, but not for wellness services. Work with your FSA administrator to determine whether your FSA funds can be applied to your visit.

The following policies will be included in your client portal for review and e-signature:

• Privacy Notice

• Patient Financial Responsibility

• Consent for Occupational Therapy

• Consent for Wellness Services

• Release of Information

• Cancellation Policy

• Good Faith Estimate (when applicable)

Signing the above forms prior to your visit will maximize the time in your session.

Good Faith Estimate Notice & Your Rights

This is a federally required disclosure under the No Surprises Act, effective Jan 1, 2022.

• If you are uninsured or choose not to use your insurance, you have the right to receive a “Good Faith Estimate” (GFE) explaining how much your care is expected to cost.

• Under the law, healthcare providers must give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a GFE for the total expected cost of any non-emergency items or services.

• Your provider should give you a GFE in writing at least 1 business day before your service, through your secure client portal. You will be requested to electronically sign the document prior to your session.

• You can also ask your provider, and any other provider you choose, for a GFE before you schedule an item or service.

• If you receive a bill that is at least $400 more than your GFE, you can dispute the bill.

• For questions or more information about your right to a Good Faith Estimate, visit: www.cms.gov/nosurprises.