The Oregon Physical Therapy Association. presents. Medical Screening for the Physical Therapist. Home Study Course

Size: px
Start display at page:

Download "The Oregon Physical Therapy Association. presents. Medical Screening for the Physical Therapist. Home Study Course"

Transcription

1 The Oregon Physical Therapy Association presents Medical Screening for the Physical Therapist Home Study Course Medical Screening Full Course Medical Screening Refresher Course Instructors Richard Gicking, MD, FACP Jill Pruett, MD

2 Medical Screening for the Physical Therapist Home Study Course Course Descriptions These courses are intended to be stimulating and practical with an interactive format. Physical therapists, occupational therapists, occupational therapy assistants, speech language pathologists, and physical therapist assistants may find this course information useful in their practice settings. Course content is not intended for use outside the scope of the learner s license or regulation. Clinical continuing education should not be taken by individuals who are not licensed or otherwise regulated, except as they are involved in a specific plan of care. Medical Screening Course 12-Hour The 12-hour course is designed to introduce the physical therapist to the presentation of illness and the concept of differential diagnosis. The standard techniques of the medical history and physical examination will be explored in detail. Realistic case-based presentations will be utilized to prepare the participant to recognize situations requiring referral to a physician. Particular detail will be focused on the differential diagnosis of pain syndromes, highlighting conditions requiring emergent and urgent physician referral. In addition, a summary of diagnostic imaging modalities will be reviewed, with emphasis on their sensitivity and limitations. An overview of pharmacotherapy will be provided as well, with emphasis on medication that could influence response to physical therapy. Medical Screening Refresher 6-Hour The 6-hour course is designed as a refresher for the therapist who has completed the initial 12-hour Medical Screening course. A more condensed overview of the basic components of the history and physical examination, update in imaging and pharmacology will be presented. More detailed case-based presentations will allow refinement of the therapist s skills in differential diagnosis and appropriate referral. Cases will include typical and atypical presentation of disease, how to recognize unstable and potentially catastrophic illness with minimal symptoms, and techniques to elicit psychopathology that may enhance a patient s symptomatology or impair their response to physical therapy. Course Objectives Upon completion of this course, participants will have an understanding of: the types of musculoskeletal pain, pain sources and innervation. the concept of referred visceral organ and structure pain that can present as musculoskeletal pain and the most common serious disorders which may appear to be musculoskeletal in origin. regional medical differential diagnosis of serious musculoskeletal pain problems including cervical, shoulder, thoracic, chest lumbar, SI, hip and leg. dermatological disorders related to injury, infectious conditions, cancer, and other skin disorders, which may produce pain. medications and side effects. infectious disease, including upper respiratory tract infection, gastroenteritis, urinary tract infection, meningitis, hepatitis, tuberculosis, and HIV infection. first aid issues in the therapy department, including asthma, cardiovascular disorders, blood pressure assessment, hypertension, syncope, diabetes, hypoglycemia, and allergic reactions. radiology and imaging techniques. the parameters of scanning exam for skin, neck, chest, abdomen and inguinal regions. practical skills to deal with patient emotions and attitudes and to decrease stress.

3 Instructors Richard Gicking, MD, FACP, received his medical degree from George Washington University School of Medicine, Washington, D.C. and completed his Internal Medicine residency in 1995 at the Legacy Internal Medicine Program, Portland, Oregon. Prior to joining the Legacy Clinic at Good Samaritan in 1997, Dr. Gicking maintained a very busy primary care clinic serving a large rural logging community. Dr. Gicking has served as the Vice Chair of Medicine at Legacy Portland Hospitals since He also currently serves on the Patient Care Committee and Managed Care Committee for the Legacy Portland Clinics and the Pharmacy and Therapeutics Committee for Legacy Portland Hospitals. Dr. Gicking s current internal medicine/ geriatrics practice includes outpatient continuity care as well as hospital management for general adult populations and frail elderly panels as well as hospital teaching and supervision of Medicine residents and medical students. Jill Pruett, MD, received her medical degree from Cornell University Medical College, New York, New York and completed her Internal Medicine Chief Residency in 1997 at the Oregon Health Sciences University, Portland, Oregon. Dr. Pruett began her practice at the Mullikin Medical Center prior to joining Legacy Good Samaritan Hospital in 1999 where she is a hospitalist and Legacy IM Program ward attending. Dr. Pruett is board certified in internal Medicine and belongs to the American College of Physicians and National Association of Inpatient Physicians. Additional Information Home Study Basics - How Does It Work? Use the enclosed form to order your DVD set from OPTA. OPTA will mail you a confirmation letter, DVD set, course handouts, timecode postcard, exam, and evaluation form. View the full course and fill in the timecode postcard while viewing the material. Complete the exam. Mail the timecode postcard, exam, and evaluation form to OPTA for verification of codes and scoring of exam. OPTA will mail you the CE certificate, upon receipt of your timecode postcard, passing exam, and completed evaluation form. Test Policy You can receive one test per purchased course if requested at the time of purchase. Simply check the box on the order form that says "I am taking this course for CE credits and willl need a test administered as a part of those requirements." It is the policy that OPTA will not release the test answers to individuals who have taken the Medical Screening course. The questions may be used again on future exams; therefore, giving out the answers would jeopardize the credibility of the exam. It is our desire to provide quality education to the physical therapy profession. We believe the Medical Screening course is a valuable tool that enables physical therapists to practice in a knowledgeable manner when working with Direct Access. Individuals wishing to complete the examination for CE credits will have one attempt under one purchase price. If an individual does not pass with a passing rate of 80% he or she will need to retake the entire course. Test results will be provided upon completion of the test and will be mailed within 3 weeks. Technical Information The home study (DVD) course is fully compatible with Windows operating systems. The DVDs are designed to play on the DVD drive of your PC, MAC or your home DVD player. Each DVD has a very simple beginning menu with the option of Play All or you can go to one of the specific sections that is contained on the DVD. You can stop at any point and return to the menu. Please note that you must have a DVD driver or player in order to view the course Continuing Education Credits Your course completion certificate will be mailed to you after viewing the full DVD set, completing the timecode postcard and exam and returning both to OPTA for verification of the timecodes and scoring of exam. This is mandated by the Oregon Physical Therapist Licensing Board to ensure the full course was viewed. Medical Screening Course: You will receive a course completion certificate for 12 CE hours. Medical Screening Refresher Course: You will receive a course completion certificate for 6 CE hours. Purchasing Information You can receive one test per purchased course if requested at the time of purchase. The individual purchasing the course MUST be the individual who completes the test. Therefore, the registration must reflect the actual user s personal information. The purchase price includes access to the course and materials, as well as a test for CE credits (limit one attempt). If attempting to purchase for more than one person with one credit card, each course must be purchased individually so that each user s information is entered along with their individual ID numbers. Personal course information does not have to match billing information.

4 Oregon Physical Therapy Association 147 SE 102nd Avenue Portland, OR Questions? OPTA Tollfree Fax Order on-line at

5 Oregon Physical Therapy Association Medical Screening Home Study Course Order Form Name Work Facility Address Home Work City State Zip Work Phone Home Phone Fax APTA Membership # Oregon License # Please mark one: I am taking this course for CE credits and will need a test administered as a part of those requirements. I am taking this course strictly for continuing education and do not require a test. Note: You will not receive a CE certificate if you choose this option. Fees 12-Hour Home Study Course: PT/PTA OPTA Member $295 PT/PTA Non Member or Other Health Professional $445 6-Hour Home Study Refresher Course: PT/PTA OPTA Member $195 PT/PTA Non Member or Other Health Professional $295 Payment Check, made payable to OPTA or Visa MasterCard American Express Amount Due: $ Card Number Corporate Card? Expiration Date Amount Authorized Yes No Name on Card Signature Card Billing Address City State Zip Purchasing Information You can receive one test per purchased course if requested at the time of purchase. The individual purchasing the course MUST be the individual who completes the test. Therefore, the registration must reflect the actual user s personal information. The purchase price includes access to the course and materials, as well as a test (if requested) for CE credits (limit one attempt). If attempting to purchase for more than one person with one credit card, each course must be purchased individually so that each user s information is entered along with their individual ID numbers. Personal course information does not have to match billing information. Mail order form with payment to: OPTA 147 SE 102nd Avenue Portland, OR Order on-line at Questions? Contact OPTA at , tollfree or via at info@opta.org

GREENFIELD COMMUNITY COLLEGE H e a l t h Records Room N408 One College Drive, Greenfield, Massachusetts 01301 TEL: (413) 775-1431 FAX: 775-1434

GREENFIELD COMMUNITY COLLEGE H e a l t h Records Room N408 One College Drive, Greenfield, Massachusetts 01301 TEL: (413) 775-1431 FAX: 775-1434 GREENFIELD COMMUNITY COLLEGE H e a l t h Records Room N408 One College Drive, Greenfield, Massachusetts 01301 TEL: (413) 775-1431 FAX: 775-1434 HEALTH REQUIREMENTS M e d i c a l Assistant Certificate (

More information

NURSING STUDENT HEALTH & IMMUNIZATION RECORDS

NURSING STUDENT HEALTH & IMMUNIZATION RECORDS NURSING STUDENT HEALTH & IMMUNIZATION RECORDS *********************************** COMPLETE THE ATTACHED HEALTH PACKET AND SUBMIT TO THE NURSING DEPARTMENT NO LATER THAN THE ASN ORIENTATION. **************************************

More information

Master of Physician Assistant Studies Course Descriptions for Year I

Master of Physician Assistant Studies Course Descriptions for Year I FALL TERM COURSES: Master of Physician Assistant Studies Course Descriptions for Year I PHAC 7230 Fundamentals in Pharmacology for Health Care I Credit Hrs: 3 This course will build on foundational knowledge

More information

William O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737

William O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737 William O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737 Workers Compensation Form First Name MI Last Name Sex Date of Birth Social Security

More information

Health Information Form for Adults

Health Information Form for Adults A. IDENTIFICATION B. EMERGENCY CONTACTS Name (Last) (First) (Middle) Maiden Name Primary Alternate In Case of Emergency, Notify: Primary Contact Name (Last) (First) (Middle) Relationship Home Work Home

More information

SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink)

SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink) SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink) Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey

More information

International Postprofessional Doctoral of Physical Therapy (DPT) in Musculoskeletal Management Program (non US/Canada) Curriculum

International Postprofessional Doctoral of Physical Therapy (DPT) in Musculoskeletal Management Program (non US/Canada) Curriculum International Postprofessional Doctoral of Physical Therapy (DPT) in Musculoskeletal Management Program (non US/Canada) Curriculum Effective: July 2015 INTERNATIONAL POSTPROFESSIONAL DOCTORAL OF PHYSICAL

More information

Health Information Form for Adults

Health Information Form for Adults A. Identification B. Emergency Contacts Name (Last) (First) (Middle) Maiden Name In Case of Emergency, Notify: Primary Contact Name (Last) (First) (Middle) Primary Alternate Relationship Home Work Home

More information

Email Address: _ Pre-Disability Earnings: $ City: State: Zip Code: Beneficiary Print full name & relationship to you

Email Address: _ Pre-Disability Earnings: $ City: State: Zip Code: Beneficiary Print full name & relationship to you GROUP DISABILITY INCOME INSURANCE APPLICATION HARTFORD LIFE INSURANCE COMPANY Simsbury, Connecticut 06089 Policyholder: (Participating Organization) Policy No.: Certificate No.: (Leave Blank) AGP-5697

More information

SUBSTANCE USE DISORDER SOCIAL DETOXIFICATION SERVICES [ASAM LEVEL III.2-D]

SUBSTANCE USE DISORDER SOCIAL DETOXIFICATION SERVICES [ASAM LEVEL III.2-D] SUBSTANCE USE DISORDER SOCIAL DETOXIFICATION SERVICES [ASAM LEVEL III.2-D] I. Definitions: Detoxification is the process of interrupting the momentum of compulsive drug and/or alcohol use in an individual

More information

We offer two schedules for our RN Refresher program:

We offer two schedules for our RN Refresher program: Dear Prospective Student, Thank you for your interest. Attached you will find an application to participate in an innovative R.N. Refresher course sponsored jointly by Molloy College Continuing Education

More information

Visit the book store and pick up your textbook, Administering Medications.

Visit the book store and pick up your textbook, Administering Medications. Dear Certified Medicine Aide Student, We are pleased to welcome you to our Certified Medicine Aide (CMA) course at Hagerstown Community College. In order to have a successful experience you will need to

More information

A Guide for Successfully Completing the Group Disability Insurance Evidence of Insurability Form

A Guide for Successfully Completing the Group Disability Insurance Evidence of Insurability Form A Guide for Successfully Completing the Group Disability Insurance Evidence of Insurability Form Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. So that we can

More information

Addiction Psychiatry Fellowship Rotation Goals & Objectives

Addiction Psychiatry Fellowship Rotation Goals & Objectives Addiction Psychiatry Fellowship Rotation Goals & Objectives Table of Contents University Neuropsychiatric Institute (UNI) Training Site 2 Inpatient addiction psychiatry rotation.....2 Outpatient addiction

More information

The Florida State University College of Medicine BCC 7175. Family Medicine 2012-2013. BCC 7175 2012-2013 Page 1 of 13

The Florida State University College of Medicine BCC 7175. Family Medicine 2012-2013. BCC 7175 2012-2013 Page 1 of 13 The Florida State University College of Medicine BCC 7175 Family Medicine 2012-2013 BCC 7175 2012-2013 Page 1 of 13 Table of Contents Instructors... 3 Education Director... 3 Clerkship Directors... 3 Course

More information

Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340

Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340 Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional

More information

NEW STUDENT-ATHLETE MEDICAL HISTORY FORM

NEW STUDENT-ATHLETE MEDICAL HISTORY FORM Student-Athlete Information NEW STUDENT-ATHLETE MEDICAL HISTORY FORM Name Date Birth SSN Sport Student ID Number Academic Class 1 Personal Physician s Name Phone # Person to Contact In The Event of Emergency

More information

Southwestern College Nursing & Health Occupations Programs

Southwestern College Nursing & Health Occupations Programs MEDICAL EXAMINATION FORM TO THE PHYSICIAN: Southwestern College requires a physical examination for students enrolling in the Nursing and Health Occupations Programs. A statement of your knowledge of this

More information

OUTPATIENT REHABILITATION CENTER

OUTPATIENT REHABILITATION CENTER OUTPATIENT REHABILITATION CENTER 2131 K STREET NW, SUITE 620 WASHINGTON, DC 20037 OFFICE #: 202-715-5655 FAX #: 202-715-5664 Welcome to the George Washington University Hospital Outpatient Rehabilitation

More information

ACC Nurse Refresher Course Continuing Education Department

ACC Nurse Refresher Course Continuing Education Department ACC Nurse Refresher Course Continuing Education Department Alvin Community College 3110 Mustang Road Alvin, TX 77511 Ph: 281-756-3796 Fax: 281-756-3952 Dear Prospective Nursing Refresher Student, Alvin

More information

Application for a Medical Impairment Rating (MIR)

Application for a Medical Impairment Rating (MIR) STATE OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Workers Compensation Division Medical Impairment Rating Program 220 French Landing Drive Nashville, TN 37243-1002 Phone (615) 253-1613 Fax

More information

PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE:

PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE: PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY/PROCEDURE Policy Number: MCUP3003 (previously UP100303) Reviewing Entities: Credentialing IQI P & T QUAC Approving Entities: BOARD CEO COMPLIANCE FINANCE PAC

More information

New Jersey Board of Nursing Regulations

New Jersey Board of Nursing Regulations SUBCHAPTER 14. HOMEMAKER-HOME HEALTH AIDES 13:37-14.1 Purpose and scope (a) The rules in this subchapter are designed to protect the health and safety of the public through certification of homemaker-home

More information

Stanwood Dental Care

Stanwood Dental Care Stanwood Dental Care A Family Dental Practice Committed to Wellness Welcome to our dental office! Our goal and commitment is to provide our patients with the highest quality dental care through education,

More information

New Patient Registration Information

New Patient Registration Information New Patient Registration Information ADAMS COUNTY LOCATIONS YORK COUNTY LOCATIONS Adams Health Center........ (717) 339-2620 Apple Hill................ (717) 741-8240 Aspers Health Center........ (717)

More information

2015 EDUCATIONAL PROGRAMMING Mechanical Diagnosis and Therapy : McKenzie Method

2015 EDUCATIONAL PROGRAMMING Mechanical Diagnosis and Therapy : McKenzie Method The Robin McKenzie Institute Canada 72 Pinehurst Drive, Dorchester ON N0L 1G2 PH: 1-800-463-8568 Email: mckenziecanada@bellnet.ca 2015 EDUCATIONAL PROGRAMMING Mechanical Diagnosis and Therapy : McKenzie

More information

THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS!

THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS! THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS! Please complete and sign all of the enclosed forms. Bring these forms, your physician s referral if required and any other documents required

More information

Application Form. Executive MBA

Application Form. Executive MBA Department of Business Administration The International School Application Form Executive MBA Instructions All of the following materials must be submitted before your application will be processed: Application

More information

Understanding Your Disability Benefits. Iowa Public Employees Retirement System

Understanding Your Disability Benefits. Iowa Public Employees Retirement System Understanding Your Disability Benefits Iowa Public Employees Retirement System Understanding Your Disability Benefits Iowa Public Employees Retirement System IPERS provides important protection for you

More information

Evidence-Based Practice for Public Health Identified Knowledge Domains of Public Health

Evidence-Based Practice for Public Health Identified Knowledge Domains of Public Health 1 Biostatistics Statistical Methods & Theory Evidence-Based Practice for Public Health Identified Knowledge Domains of Public Health General Public Health Epidemiology Risk Assessment Population-Based

More information

Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:

Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code: Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears

More information

MOLLOY COLLEGE Division of Continuing Education and Professional Development C.T. Cross Training Program. Home Phone ( ) Address Work Phone ( )

MOLLOY COLLEGE Division of Continuing Education and Professional Development C.T. Cross Training Program. Home Phone ( ) Address Work Phone ( ) C.T. Cross Training Program Name Home Phone ( ) Address Work Phone ( ) City St. Zip E-mail NYS. License # Expiration Date Years of Experience Name of Employer Please indicate how you intend to complete

More information

Personal Health Insurance application form

Personal Health Insurance application form Personal Health Insurance application form Please PRINT clearly ID number In this application, you and your refer to the proposed insured and the applicant. We, us, our and the company refer to Sun Life

More information

Gaston College Health Education Division Student Medical Form

Gaston College Health Education Division Student Medical Form Student Name: Date: Gaston College Health Education Division Student Medical Form Associate Degree Nursing Cosmetology Dietetic Programs Health and Fitness Science Medical Assisting Nursing Assistant Phlebotomy

More information

Step 1: Complete the attached Health Appraisal and Medical History Questionnaire, Goal Inventory, and Liability Waiver.

Step 1: Complete the attached Health Appraisal and Medical History Questionnaire, Goal Inventory, and Liability Waiver. Please use the contact information below for questions or concerns. Abraham Lincoln High School Name: Eric Nicholson Email: Eric_Nicholson@dpsk12.org Phone: 7204235043 Bruce Randolph School Name: Greg

More information

BREINING INSTITUTE 8894 GREENBACK LANE ORANGEVALE, CALIFORNIA USA 95662-4019 E-mail CERTIFICATION@BREINING.EDU www.breining.

BREINING INSTITUTE 8894 GREENBACK LANE ORANGEVALE, CALIFORNIA USA 95662-4019 E-mail CERTIFICATION@BREINING.EDU www.breining. BREINING INSTITUTE 8894 GREENBACK LANE ORANGEVALE, CALIFORNIA USA 95662-4019 E-mail CERTIFICATION@BREINING.EDU www.breining.edu Registered Addiction Specialist (RAS) Credential Application The nationally-recognized

More information

Academy of Art University Sports Medicine Returning Student-Athlete Physical Packet

Academy of Art University Sports Medicine Returning Student-Athlete Physical Packet Attention: Returning Student-Athletes Academy of Art University Sports Medicine Returning Student-Athlete Physical Packet On Behalf of the Sports Medicine Department, we look forward to another healthy

More information

75-09.1-08-02. Program criteria. A social detoxi cation program must provide:

75-09.1-08-02. Program criteria. A social detoxi cation program must provide: CHAPTER 75-09.1-08 SOCIAL DETOXIFICATION ASAM LEVEL III.2-D Section 75-09.1-08-01 De nitions 75-09.1-08-02 Program Criteria 75-09.1-08-03 Provider Criteria 75-09.1-08-04 Admission and Continued Stay Criteria

More information

PATIENT INFORMATION INSURANCE INFORMATION

PATIENT INFORMATION INSURANCE INFORMATION (mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last

More information

New England Pain Management Consultants At New England Baptist Hospital

New England Pain Management Consultants At New England Baptist Hospital New England Pain Management Consultants At New England Baptist Hospital Pain Management Center Health Assessment Dear New Pain Management Patient, Welcome to the New England Pain Management Consultants

More information

Cancellation/No Show Policy

Cancellation/No Show Policy Cancellation/No Show Policy If you are unable to keep your scheduled appointment we require a 24 hour advance notice. Failure to provide this notice will result in a $50.00 cancellation/no show fee. You

More information

Summary of Benefits. Prime (HMO-POS) and Value (HMO) January 1, 2015 December 31, 2015 G ENERATIONS A DVANTAGE 1-888-408-8285 (TTY: 711)

Summary of Benefits. Prime (HMO-POS) and Value (HMO) January 1, 2015 December 31, 2015 G ENERATIONS A DVANTAGE 1-888-408-8285 (TTY: 711) Summary of s and January 1, 2015 December 31, 2015 G ENERATIONS A DVANTAGE For more information about benefits or enrollment, call us or visit our website at www.martinspoint.org/medicare. 1-888-408-8285

More information

LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH:

LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVERS LICENSE NUMBER: STATE: EMAIL ADDRESS: MARITAL STATUS: ( ) SINGLE ( )

More information

PATIENT REGISTRATION

PATIENT REGISTRATION Orthopedic & Sports Therapy Center PATIENT REGISTRATION NAME DATE OF BIRTH SSN# FIRST MI LAST PHONE INFO: HOME BEST WAY TO CONFIRM APPOINTMENTS WORK CALL TEXT EMAIL MOBILE (TEXT) MOBILE CARRIER EMAIL ADDRESS

More information

PATIENT / VISIT INFORMATION PATIENT INFORMATION

PATIENT / VISIT INFORMATION PATIENT INFORMATION PATIENT / VISIT INFORMATION PATIENT INFORMATION Name of Patient: Date of Birth: Date of Visit: VISIT INFORMATION Please complete this form in its entirety, and present it to the registration desk when

More information

2016 Guide to Understanding Your Benefits

2016 Guide to Understanding Your Benefits 2016 Guide to Understanding Your Benefits Additional information about covered benefits available from Health Net Healthy Heart (HMO) Plan Alameda, Stanislaus counties, CA Lisa Pasillas-Le, Health Net

More information

Summary of Benefits Community Advantage (HMO)

Summary of Benefits Community Advantage (HMO) Summary of Benefits Community Advantage (HMO) January 1, 2015 - December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list

More information

Requirements for Medical Clearance: History and Physical exam within 6 months of applying for privileges

Requirements for Medical Clearance: History and Physical exam within 6 months of applying for privileges To: From: Re: Medical Staff Applicants K. Bruce Simmons, MD Director, Requirements for Medical Clearance EMPLOYEE/STUDENT HEALTH Jacobsen Hall 315-464-4260 (telephone) 315-464-5471 (fax) The New York Department

More information

Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other:

Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other: At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We

More information

Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)

Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) Patient Name: Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) (Last), (First) (Middle Initial) Address: City: State:

More information

NAPNES ONLINE CERTIFICATION IN PHARMACOLOGY CARE

NAPNES ONLINE CERTIFICATION IN PHARMACOLOGY CARE National Association for Practical Nurse Education & Service, Inc. 8607 2 nd Avenue Suite 404 A Silver Spring, MD 20910 NAPNES ONLINE CERTIFICATION IN PHARMACOLOGY CARE INTRODUCTION The National Association

More information

2015 Summary of Benefits

2015 Summary of Benefits 2015 Summary of Benefits Plans 003 and 004 H6298_14_027 accepted Summary of Benefits January 1, 2015 - December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list

More information

Seniors Health Services

Seniors Health Services Leading the way in care for seniors Seniors Health Services Capital Health offers a variety of services to support seniors in communities across the region. The following list highlights programs and services

More information

A Guide for Successfully Completing the Group Disability Insurance Evidence of Insurability Form

A Guide for Successfully Completing the Group Disability Insurance Evidence of Insurability Form A Guide for Successfully Completing the Group Disability Insurance Evidence of Insurability Form Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. So that we can

More information

Oakwood Career Ladder RESPIRATORY CARE

Oakwood Career Ladder RESPIRATORY CARE RESPIRATORY CARE Registered Respiratory Therapist Associate Degree program in Respiratory Care from JRCRTE accredited institution; Two years in the field of Respiratory Care. May include clinical rotations

More information

INSURANCE VERIFICATION FORM - Atco Medical Associates

INSURANCE VERIFICATION FORM - Atco Medical Associates INSURANCE VERIFICATION FORM - Atco Medical Associates Patient Name Date of Birth Social Security # Single Married Separated Widowed Home Phone Cell Phone # 1 Cell Phone # 2 E-Mail Address Spouse's Name

More information

Department of Geriatrics

Department of Geriatrics OUTCOMES Division of Medicine Department of Geriatrics About Cleveland Clinic Florida Cleveland Clinic Florida s medical staff are dedicated physicians who have joined the clinic as salaried doctors to

More information

FIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits. FirstMedicare Direct PPO Plus (PPO)

FIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits. FirstMedicare Direct PPO Plus (PPO) FIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits FirstMedicare Direct PPO Plus (PPO) Chatham, Hoke, Lee, Montgomery, Moore, Richmond, Scotland Counties 1 P age SECTION I - INTRODUCTION TO SUMMARY

More information

PHYSICAL MEDICINE AND REHABILITATION CLINICAL PRIVILEGES

PHYSICAL MEDICINE AND REHABILITATION CLINICAL PRIVILEGES Name: Page 1 Initial Appointment Reappointment All new applicants must meet the following requirements as approved by the governing body effective: 4/3/2013. Applicant: Check off the Requested box for

More information

PATIENT CARE TECHNICIAN/NURSING ASSISTANT 270 Hours/12 Months/Mentor Supported/Instructor Led

PATIENT CARE TECHNICIAN/NURSING ASSISTANT 270 Hours/12 Months/Mentor Supported/Instructor Led COURSE OUTLINE Course Description PATIENT CARE TECHNICIAN/NURSING ASSISTANT 270 Hours/12 Months/Mentor Supported/Instructor Led This in-depth curriculum could help individuals learn important fundamental,

More information

BREINING INSTITUTE 8894 GREENBACK LANE ORANGEVALE, CALIFORNIA USA 95662-4019 E-mail CERTIFICATION@BREINING.EDU www.breining.

BREINING INSTITUTE 8894 GREENBACK LANE ORANGEVALE, CALIFORNIA USA 95662-4019 E-mail CERTIFICATION@BREINING.EDU www.breining. BREINING INSTITUTE 8894 GREENBACK LANE ORANGEVALE, CALIFORNIA USA 95662-4019 E-mail CERTIFICATION@BREINING.EDU www.breining.edu Registered Addiction Specialist (RAS) Credential Application The nationally-recognized

More information

IMS Allergy & Immunology New Patient Registration Sheet. Personal Information

IMS Allergy & Immunology New Patient Registration Sheet. Personal Information Personal Information Today s : Patient First Name: Initial: Last Name: DOB: Age: Social Security #: E-mail: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Gender: M F Language: ENGLISH

More information

Emory Eye Center New Patient Questionnaire

Emory Eye Center New Patient Questionnaire Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions

More information

a) Each facility shall have a medical record system that retrieves information regarding individual residents.

a) Each facility shall have a medical record system that retrieves information regarding individual residents. TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER c: LONG-TERM CARE FACILITIES PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE SECTION 300.1810 RESIDENT RECORD REQUIREMENTS

More information

Mississippi Medicaid Enrollment Application (Ordering/Referring/Prescribing Provider)

Mississippi Medicaid Enrollment Application (Ordering/Referring/Prescribing Provider) This application is for the sole purpose of ordering/referring/prescribing items and services for MS Medicaid beneficiaries. This type of enrollment does not allow MS Medicaid to reimburse the applicant/provider

More information

1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840

1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840 Dear Valued Patient, 1960 Ogden St. Suite 120, Denver, CO 80218, 303-318-3840 Thank you for choosing Denver Medical Associates as your healthcare provider. We strive to provide you with the best possible

More information

PATIENT INFORMATION INSURANCE INFORMATION

PATIENT INFORMATION INSURANCE INFORMATION PATIENT INFORMATION NAME DATE ADDRESS CITY ST ZIP PHONE(H) (C) (W) DATE OF BIRTH EMAIL AGE SEX: M F SS#(optional) EMPLOYER OCCUPATION ARE YOU CURRENTLY: MARRIED PARTNERED DIVORCED WIDOWED SINGLE SPOUSE/PARTNER

More information

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - 4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)

More information

Outpatient Rehabilitation Department

Outpatient Rehabilitation Department Outpatient Rehabilitation Department Dear You have been referred to our office for an outpatient (Occupational Therapy, Physical Therapy, Speech Therapy) evaluation on at. Please arrive 15 minutes early

More information

LEGAL NAME (Must EXACTLY match your United States government issued ID):

LEGAL NAME (Must EXACTLY match your United States government issued ID): PLEASE PRINT LEGIBLY CALIFNIA CERTIFYING BOARD F MEDICAL ASSISTANTS A Private Non-Profit Corporation PO Box 462 Placerville CA 95667 Toll-free (866) 622-2262 Fax (530) 622-8254 Email: ccbma@aol.com Website:

More information

January 1, 2015 December 31, 2015 Summary of Benefits. Altius Advantra (HMO) H8649-003 80.06.361.1-UTWY A

January 1, 2015 December 31, 2015 Summary of Benefits. Altius Advantra (HMO) H8649-003 80.06.361.1-UTWY A January, 205 December 3, 205 Summary of Benefits H8649-003 80.06.36.-UTWY A Y0022_205_H8649_003_UT_WYa Accepted /204 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of

More information

HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME

HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME We are pleased you have chosen us for your physical therapy needs. Our office is committed to providing

More information

Acute Rehabilitation Center

Acute Rehabilitation Center Acute Rehabilitation Center Acute Rehabilitation Courtyard Our Center Community Westview Hospital's Acute Rehabilitation Center and programs are specially designed to meet the needs of our patients and

More information

West Florida Rehabilitation Institute Wellness Program

West Florida Rehabilitation Institute Wellness Program West Florida Rehabilitation Institute Wellness Program Thank you for your interest in our Wellness Program! As a member, you will enjoy the benefits of our modern Fitness Center and/or warm water pool.

More information

Kentucky Appalachian Rural Rehabilitation Network

Kentucky Appalachian Rural Rehabilitation Network Kentucky Appalachian Rural Rehabilitation Network 5th Annual KARRN Conference: Issues Related to Spinal Cord Injury, Stroke and Brain Injury The Perkins Conference Center, Eastern Kentucky University Richmond,

More information

HNE Premier 1 (HMO) and HNE Premier 2 (HMO)

HNE Premier 1 (HMO) and HNE Premier 2 (HMO) 2016 Medicare Advantage Summary of Benefits HNE Premier 1 (HMO) and HNE Premier 2 (HMO) January 1, 2016 - December 31, 2016 H8578_2016_429 Accepted HNE MEDICARE ADVANTAGE ENROLLMENT KIT 2016 SECTION I

More information

Health Professionals who Support People Living with Dementia

Health Professionals who Support People Living with Dementia Clinical Access and Redesign Unit Health Professionals who Support People Living with Dementia (in alphabetical order) Health Professional Description Role in care of people with dementia Dieticians and

More information

Electronic Health Records Intake Form

Electronic Health Records Intake Form Dr. Sam Yoder, D.C. 101 Winston Way Ste B Campbellsville, KY 42718 Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Address: Last

More information

Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591

Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas

More information

NAPNES CERTIFICATION IN LONG-TERM CARE

NAPNES CERTIFICATION IN LONG-TERM CARE National Association for Practical Nurse Education & Service, Inc. Multi- Skilled Nursing Certification Company NAPNES CERTIFICATION IN LONG-TERM CARE INTRODUCTION The National Association for Practical

More information

How To Manage A Pediatric Inpatient Rotation At American University Of Britain

How To Manage A Pediatric Inpatient Rotation At American University Of Britain Pediatric Residency Program American University of Beirut In patients Experience Goals and Objectives The in patient rotation at AUB MC is based on a general pediatric ward in a tertiary care setting with

More information

January 1, 2015 December 31, 2015 Summary of Benefits. Advantra (HMO) H3928-001 80.06.360.1-LA1

January 1, 2015 December 31, 2015 Summary of Benefits. Advantra (HMO) H3928-001 80.06.360.1-LA1 January, 205 December 3, 205 Summary of Benefits H3928-00 80.06.360.-LA Y0022_205_H3928_00_LA Accepted 9/204 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of what we

More information

2015 Summary of Benefits

2015 Summary of Benefits 2015 Summary of Benefits Effective January 1, 2015, through December 31, 2015 H3909 Y0041_H3909_PC_15_18889 Accepted 09/01/2014 Section I: Introduction to Summary of Benefits You have choices about how

More information

Welcome to the UW Health Sports Medicine Clinic

Welcome to the UW Health Sports Medicine Clinic Welcome to the UW Health Sports Medicine Clinic You are scheduled on to see. In order to best serve your needs, please bring with you to your appointment the following: 1. Completed Questionnaire (enclosed)

More information

[2015] SUMMARY OF BENEFITS H1189_2015SB

[2015] SUMMARY OF BENEFITS H1189_2015SB [2015] SUMMARY OF BENEFITS H1189_2015SB Section I You have choices in your health care One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare

More information

A Guide to Patient Services. Cedars-Sinai Health Associates

A Guide to Patient Services. Cedars-Sinai Health Associates A Guide to Patient Services Cedars-Sinai Health Associates Welcome Welcome to Cedars-Sinai Health Associates. We appreciate the trust you have placed in us by joining our dedicated network of independent-practice

More information

Patient History Information

Patient History Information Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:

More information

OREGON HEALTH CARE CAREERS

OREGON HEALTH CARE CAREERS Career School Degree Required Description Art Therapy Marylhurst Masters Art therapists use drawings and other art/media forms to assess, treat, and rehabilitate patients with mental, emotional, physical,

More information

2015 Medicare Advantage Summary of Benefits

2015 Medicare Advantage Summary of Benefits 2015 Medicare Advantage Summary of Benefits HNE Medicare Premium No Rx and HNE Medicare Basic No Rx January 1, 2015 - December 31, 2015 H8578_2015_034 Accepted HNE MEDICARE ADVANTAGE ENROLLMENT KIT 2015

More information

Thank you for making an appointment with our office. We look forward to serving your visual needs.

Thank you for making an appointment with our office. We look forward to serving your visual needs. Dear New Patient, Thank you for making an appointment with our office. We look forward to serving your visual needs. Enclosed you will find our New Patient Questionnaires. Please complete these and fax

More information

English Language Fellow Program Health Verification Form

English Language Fellow Program Health Verification Form English Language Fellow Program Health Verification Form You are receiving this Health Verification Form (HVF) because your application was reviewed and determined to be eligible for consideration for

More information

2016 Summary of Benefits

2016 Summary of Benefits 2016 Summary of Benefits Health Net Violet Option 3 (PPO) Douglas and Josephine counties, OR Benefits effective January 1, 2016 H5520 Health Net Life Insurance Company H5520_2016_0202 CMS Accepted 09162015

More information

FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST

FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST Department of Public Safety - Technology 11400 Greenstone Avenue Santa Fe Springs California 90670 Tracy Rickman, Academy Coordinator (562) 941-4082 Class FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST

More information

Documentation Guidelines for Physicians Interventional Pain Services

Documentation Guidelines for Physicians Interventional Pain Services Documentation Guidelines for Physicians Interventional Pain Services Pamela Gibson, CPC Assistant Director, VMG Coding Anesthesia and Surgical Divisions 343.8791 1 General Principles of Medical Record

More information

How To Pay For Care At A Clinic

How To Pay For Care At A Clinic WELCOME TO THE HUMAN PERFORMANCE AND REHABILITATION CENTERS, INC. Welcome to Human Performance and Rehabilitation Centers, Inc. The following information will give you a better understanding of our payment

More information

Adult Spine Rotation Specific Evaluation Orthopaedic Surgery Training Program School of Medicine, Queen s University

Adult Spine Rotation Specific Evaluation Orthopaedic Surgery Training Program School of Medicine, Queen s University Adult Spine Rotation Specific Evaluation Orthopaedic Surgery Training Program School of Medicine, Queen s University CanMEDS Roles / Competencies Name: PGY Rotation Dates: s s Exceeds N/A Attending Staff:

More information

Dallas Neurosurgical and Spine Associates, P.A Patient Health History

Dallas Neurosurgical and Spine Associates, P.A Patient Health History Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of

More information

Print Provider Packet and schedule an appointment with your healthcare provider to complete the packet.

Print Provider Packet and schedule an appointment with your healthcare provider to complete the packet. Due Dates: Incoming Fall Students July 15 th Incoming Spring Students December 15 th Incoming Summer Students July 15 th THESE FOLLOWING ARE REQUIRED BY NJ STATE LAW AND ROWAN UNIVERSITY POLICY. FAILURE

More information

HOUSE OF REPRESENTATIVES - FLOOR VERSION

HOUSE OF REPRESENTATIVES - FLOOR VERSION HOUSE OF REPRESENTATIVES - FLOOR VERSION STATE OF OKLAHOMA nd Session of the rd Legislature () HOUSE BILL By: Mulready of the House and Brinkley of the Senate AS INTRODUCED An Act relating to professions

More information

To provide standardized Supervised Exercise Programs across the province.

To provide standardized Supervised Exercise Programs across the province. TITLE ALBERTA HEALTHY LIVING PROGRAM SUPERVISED EXERCISE PROGRAM DOCUMENT # HCS-67-01 APPROVAL LEVEL Executive Director Primary Health Care SPONSOR Senior Consultant Central Zone, Primary Health Care CATEGORY

More information