1 Welcome to VibrantCare Rehabilitation Thank you for choosing VibrantCare Rehabilitation. We know you and your physician have a choice in your therapy provider and we are pleased you have chosen us. Please wear comfortable clothing and shoes on the day of your appointment. This introduction letter is to help familiarize you with the rehabilitation experience you will have while at VibrantCare Rehabilitation. We are looking forward to helping you onto the road to recovery. Here is what you can expect after you have checked in and completed all of your paperwork: Your Licensed Physical or Occupational Therapist will complete your evaluation, prescribe an individualized treatment plan and provide you with a home program. During your first visit, your treatment plan will be initiated and reviewed with you to ensure full understanding. During your first and subsequent visits, your primary therapist will enlist the assistance of other team members to work with you. Our team may consist of Licensed Therapists, Certified Therapist Assistants, Exercise Physiologists and Rehab Team Members who are specially trained to carry out all aspects of your treatment program. Your scheduled appointment allows your primary therapist specialized time with you. If you cannot make your appointment, please contact us to reschedule as soon as possible. Please be mindful of the importance we place on every appointment. Any one of our VibrantCare staff will assist you while you are in the clinic. Never be shy! If you have questions or concerns, please don t hesitate to let us know. Thank you again for choosing VibrantCare Rehabilitation VibrantCare 2011 Proprietary Information/Reproduction by VibrantCare Only
2 NEW PATIENT REGISTRATION FORM PAGE 1 OF 2 PERSONAL INFORMATION Patient ID#: Referral Date: Last Name: First Name: Date of Birth: Sex: Marital Status: Male Single Divorced Female Married Widowed Street Address: City: State: Zip Code: Past Patient? Yes No Home Phone #: Cell Phone #: Work Phone #: SS#: Preferred Method of Appointment Reminders Phone Call Text Message to Cell Phone (please provide address): PRIMARY INSURANCE INFORMATION Primary Insurance Company: Policy or Claim #: Group # / Policy Holder s Employer: Policy Holder: Self Other If other, please indicate: Name of Policy Holder: ; Relationship to Patient: Phone #: ; Date of Birth: ; SS# (Required for TriWest): Adjuster/Contact: Adjuster Phone/Fax: Coverage %: Deductible / Max Benefits: Auth# # of Visits: Auth from to Copay: $ SECONDARY INSURANCE INFORMATION Secondary Insurance Company: Policy or Claim #: Group # / Policy Holder s Employer: Policy Holder: Self Other If other, please indicate: Name of Policy Holder: ; Relationship to Patient: Phone #: ; Date of Birth: ; SS# (Required for TriWest): Adjuster/Contact: Adjuster Phone/Fax: Coverage %: Deductible / Max Benefits: Auth# # of Visits: Auth from to Copay: $ EMERGENCY CONTACT Name: Phone #: Relationship to Patient: FOR CLINIC USE ONLY Tx Type: PT OT ST Other Date of Injury / Onset: Diagnosis 1 (Desc/ICD.9): Diagnosis 2 (Desc/ICD.9): Post-Op? Yes (Dt: ) No Evaluation: Date: Time: Referring Physician: RMT ID#: Evaluating Therapist: Financial Class: MR (10) CM (40) MD (70) CH (18) WC (50) SP (80) MC (20) MV (60) CP (99) MCC(30) LG (65) Patient Signature: Date: VibrantCare 2011 Proprietary Information/Reproduction by VibrantCare Only
3 NEW PATIENT REGISTRATION FORM PAGE 2 OF 2 MINOR/GUARDIAN Is patient a Minor? Yes No If yes, Name of Guardian/Guarantor: Relationship to Patient: Phone #: REFERRING PHYSICIAN Referring Physician: Phone #: NPI#: Fax #: UPIN: OTH000 / Address: City: State: Zip Code: VibrantCare 2011 Proprietary Information/Reproduction by VibrantCare Only
4 PAST MEDICAL HISTORY FORM Patient Name: Date: Are you presently working? Yes No Date of next physician s visit: / / Date of injury / onset: / / Have you ever had these symptoms before? Yes No Check which apply to your symptoms: Work related injury Recurrence of previous injury Motor vehicle accident Injury related to lifting Injury related to falling Cause unknown Athletic / recreational injury Other: Have you had a related surgery? Yes No Do you have, or have you had any of the following? Yes No Yes No Diabetes Allergies to Aspirin Chest Pain / Angina Allergies to Heat High Blood Pressure Allergies / Poor tolerance to Cold Heart Disease Other Allergies Heart Attack Hernia Heart Palpitations Seizures Pacemaker Metal Implants Headaches Dizziness / Fainting Kidney Problems Recent Fractures Are you pregnant? Surgeries Cancer Skin Abnormalities Osteoporosis Sexual Dysfunction Bowel / Bladder Abnormalities Nausea / Vomiting Urine Leakage Ringing in your ears Asthma / Breathing Difficulties Rheumatoid Arthritis Liver / Gallbladder Problems Special Diet Guidelines Smoking Hypoglycemia Stroke/CVA Other: If yes on any of the above, please briefly explain and give approximated date: Is there any other information regarding your past medical history that we should know about? Are you presently taking Medication? Yes No If yes, please list what medications and for what condition: Trust. Experience. Results.
5 Do you participate in any sports, exercise programs, or activities on a regular basis? Yes No The services of a social worker are available through VibrantCare. Please indicate if you feel you have need of such services. Yes No Please indicate below where your symptoms are located. KEY: Numbness ======== Pins & Needles ooooooo Burning Pain xxxxxxxx Stabbing Pain / / / / / / / / If you are having pain, please rate the intensity of your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain possible:. Patient Signature Date Signature of Guardian if patient is a minor Date Therapist Signature / / Date Trust. Experience. Results.
6 Consent to Treat Form I hereby acknowledge the communication and description of my condition/diagnosis, presenting signs and symptoms, pertinent evaluation findings, contraindications and precautions to treatment, expected benefits of treatment, and reasonable alternatives to treatment when applicable by a VibrantCare Rehabilitation clinician. I further acknowledge my consent to receive treatment was voluntary and obtained following my initial evaluation that was performed for the determination of the appropriateness of my plan of care/treatment program. I understand that I have the right to ask questions and receive adequate response to my questions at any time during the course of my care; and that I can terminate treatment at any time I wish to discontinue. Patient Name (print): Signature: Date: Surrogate (if required): Trust. Experience. Results.
7 Patient Name: Account Number: EVAL DATE & TIME Referral ID#: IMPORTANT INSURANCE INFORMATION Most insurance policies cover physical therapy/occupational therapy care, but this office makes no representation that your insurance company does or does not. Insurance policies can differ greatly in terms of deductible amounts and percentage of coverage for care. Please be aware that not all services are a covered benefit under different insurance policies. You are responsible for knowing what services are or are not covered. Your insurance policy is a contract between you and your insurance company. We are NOT a party to that contract. We will not be involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, etc. other than to supply factual information as necessary. I understand that VibrantCare Rehabilitation does not have access to the details of my insurance plan and it is my responsibility to understand and familiarize myself with all aspects of my health benefits. The following section is provided for you as a courtesy to help you understand your physical therapy/occupational therapy benefits. Please call your insurance to verify that the benefits stated below are accurate and according to your policy. PAYMENT POLICY AND BILLING PROCEDURES You are responsible for any copay per visit and/or deductible not covered by your insurance company. Copayment is required at the time of each visit. VibrantCare will bill you for any outstanding coinsurance/deductible responsibilities. We will collect $10 towards your coinsurance; you will receive a statement for any unpaid balance. We will collect $25.00 ($50 if deductible is more than $500) toward your deductible and you will receive a statement for any unpaid balances. Payment is due in full at the time of your visit unless prior arrangements have been made. We accept cash, check and Visa, MasterCard, American Express and Discover bankcards. There is a $25 charge for all returned checks. You will receive a monthly statement that will show you the status of your account. CONSENT TO TREAT I understand that I have been referred for rehabilitative treatment and care to VibrantCare Outpatient Rehabilitation. VibrantCare will perform an Initial Evaluation and then describe for me any individual treatment plan. I understand that I have the right to ask and have any questions answered prior to receiving any treatment, including any risks or alternative to the treatment plan. By signing this agreement, I consent to have VibrantCare Outpatient Rehabilitation provide an Initial Evaluation as prescribed by my physician and/or recommended by my therapist. SUPPLIES/MEDICAL RECORDS POLICY SUPPLIES: Payment for all supplies not covered by insurance is due at the time of service. MEDICARE PATIENTS: Medicare does not cover supplies. You are responsible for payment for all supplies used in your treatment at the time of each visit. WORKERS COMPENSATION: Workers Compensation benefits will be reviewed, however this does not guarantee payment. In the event of denial, this account will become your responsibility. MEDICAL RECORDS: Medical records will be provided within 30 days after the date of your request. If you require Medical records prior to 30 days, you will be billed a $45 convenience charge. By signing below I hereby acknowledge that the statements above are true and correct to the best of my knowledge. I understand fully the payment policies and billing procedures of VibrantCare Outpatient Rehabilitation. I hereby authorize VibrantCare Outpatient Rehabilitation to furnish my insurance company(s), attorney, or legal representative all information, which said parties might request concerning my present illness or injury. I hereby assign VibrantCare Outpatient Rehabilitation all money to which I am entitled for medical expenses related to the service reported herein, but not to exceed my indebtedness to VibrantCare Outpatient Rehabilitation. It is understood that any money received from the above named parties over & above my indebtedness will be refunded to me when my bill is paid in full. I am financially responsible to VibrantCare Outpatient Rehabilitation for charges not covered by my insurance company. I certify by my signature that I have read and agree to this information. Patient Name (please print): Signature: Date: Relationship to Patient (Self, Parent or Guardian): Witness: VibrantCare Rehabilitation 2013 Proprietary Information/Reproduction by VibrantCare Rehabilitation Only Rev: 12/2013
8 Notice of Privacy Practices Effective April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The terms of this Notice of Privacy Practices apply to VibrantCare Rehabilitation and each of its subsidiaries, affiliates, and entities managed or controlled by VibrantCare, including the corporate office and its employees. All of the entities will share personal health information of patients as necessary to carry out treatment, payment, and health care operations as permitted by law. We are required by law to maintain the privacy of our patients personal health information and to provide patients with notice of our legal duties and privacy practices with respect to personal health information. We are required to abide by the terms of this Notice for as long as it remains in effect. We reserve the right to change the terms of this Notice of Privacy Practices as necessary and to make a new Notice effective for all personal health information maintained by VibrantCare Rehabilitation. We are also required to inform you that there may be a provision of State law that relates to the privacy of your health information that may be more stringent than a standard or requirement under the Federal Health Insurance Portability and Accountability Act. A copy of any revised Notice of Privacy Practices or information pertaining to a specific State law may be obtained by mailing a request to the Privacy Officer, VibrantCare Rehabilitation, 2270 Douglas Blvd. #112, Roseville, CA USES AND DISCLOSURES OF YOUR PERSONAL HEALTH INFORMATION Authorization and Consent: Except as outlined below, we will not use or disclose your personal health information for any purpose other than treatment, payment or health care operations unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing unless we have taken any action in reliance on the authorization. Uses and Disclosures for Treatment: With your agreement, we will make uses and disclosures of your personal health information as necessary for your treatment. Doctors and nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to your course of treatment that may include procedures, medications, tests, medical history etc. Uses and Disclosures for Payment: With your agreement, we will make uses and disclosures of your personal health information as necessary for payment purposes. During the normal course of business operations, we may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you. We may use your information to prepare a bill to send to you or to the person responsible for your payment. Uses and Disclosures for Health Care Operations: With your agreement, we will use and disclose your personal health information as necessary, and as permitted by law, for our health care operations, which may include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, we may use and disclose your personal health information for purposes of improving the clinical treatment and patient care. Individuals Involved In Your Care: With your written or oral agreement we may from time to time disclose your personal health information to designated family, friends, and others who are involved in your care or in payment of your care in order to facilitate that person s involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest, we may share limited personal health information with involved individuals without your approval. We may also disclose limited personal health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you. Business Associates: Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, outcomes data collection, legal services, etc. At times it may be necessary for us to provide your personal health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your information. Appointments and Services: We may contact you to provide appointment reminders or information about your treatment or other health-related benefits and services that may be of interest to you. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your personal health information from us by alternative means or at alternative locations. For instance, if you wish appointment reminders to not be left on voice mail or sent to a particular address, we will accommodate reasonable requests. You also have the right to request that we not send you any future marketing materials and we will use our best efforts to honor such request. You may make your requests by sending your name and address to Privacy Officer, 2270 Douglas Blvd. # 112, Roseville, CA Research: In limited circumstances, we may use and disclose your personal health information for research purposes. In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements applied by an FORM 2.6a (07/2007) / VibrantCare Page 1 of 2
9 Notice of Privacy Practices (continued) Institutional review board which oversees the research or by representations of the researchers that limit their use and disclosure of patient information. Other Uses and Disclosures: We are permitted and/or required by law to make certain other uses and disclosures of your personal health information without your consent or authorization for the following: Any purpose required by law. Public health activities, such as required reporting of disease, injury, birth and death, or required public health investigations. If we suspect child abuse or neglect; if we believe you to be a victim of abuse, neglect, or domestic violence. To the Food and Drug Administration to report adverse events, product defects, or to participate in product recalls. To your employer when we have provided health care to you at the request of your employer; To a government oversight agency conducting audits, investigations, or civil or criminal proceedings. Court or administrative ordered subpoena or discovery request; To law enforcement officials as required by law to report wounds and injuries and crimes; To coroners and/or funeral directors consistent with law; If necessary to arrange an organ or tissue donation from you or a transplant for you; If you are a member of the military; we may also release your personal health information for national security or intelligence activities; and To workers compensation agencies for workers compensation benefit determination. RIGHTS THAT YOU HAVE REGARDING YOUR PERSONAL HEALTH INFORMATION Access to Your Personal Health Information: You have the right to copy and/or inspect much of the personal health information that we retain on your behalf. All requests for access must be made in writing and signed by you or your legal representative. You may obtain a Patient Access to Health Information Form from the front office person. Amendments to Your Personal Health Information: You have the right to request in writing that personal health information that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All amendment requests, must be in writing, signed by you or your legal representative, and must state the reasons for the amendment/correction request. If an amendment or correction request is made, we may notify others who work with us if we believe that such notification is necessary. You may obtain an Amendment Request Form from the front office person or individual responsible for medical records. Accounting for Disclosures of Your Personal Health Information: You have the right to receive an accounting of certain disclosures made by us of your personal health information after April 14, Requests must be made in writing and signed by you or your legal representative. Accounting Request Forms are available from the front office person or individual responsible for medical records. The first accounting in any 12-month period is free; you will be charged a fee for each subsequent accounting you request within the same 12-month period. You will be notified of the fee at the time of your request. Restrictions on Use and Disclosure of Your Personal Health Information: You have the right to request restrictions on uses and disclosures of your personal health information for treatment, payment, or health care operations. We are not required to agree to your restriction request, but will attempt to accommodate reasonable requests when appropriate. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction by sending such termination notice to the individual responsible for medical records. Complaints: If you believe your privacy rights have been violated, you can file a complaint in writing with the Privacy Officer, 2270 Douglas Blvd. # 112, Roseville, CA You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C. in writing within 180 days of a violation of your rights. There will be no retaliation for filing a complaint. Workers Compensation: For patients whose medical treatment is covered under a state workers compensation program, please note the following: Disclosure of your protected health information (PHI) for purposes of providing treatment and obtaining payment under the state s workers compensation is governed by the state workers compensation regulations and procedures. Therefore, we are not obligated to secure a written authorization as otherwise required by HIPAA in order to disclose your PHI for workers compensation purposes, nor may you restrict our use or disclosure of your PHI for workers compensation purposes. Written consent to use or disclose your PHI may be required pursuant to our internal policies and/or state workers compensation program rules in order to process your claims. Failure to provide any required written consent may result in your financial liability for medical services and supplies. FOR FURTHER INFORMATION: If you have questions or need further assistance regarding this Notice, you may contact the Privacy Officer, VibrantCare Rehabilitation, 2270 Douglas Blvd. #112, Roseville, CA or Signature: Date: Patient (or representative) FORM 2.6a (07/2007) / VibrantCare Page 2 of 2
10 BUSINESS DISCLOSURES TO INDIVIDUALS INVOLVED IN PATIENT S CARE There may be times when it is necessary for an individual directly involved in your care to call the facility or the Central Billing Office to inquire about your personal health information or billing information. Please take a few moments to complete this form. I authorize VibrantCare Rehabilitation to disclose my health information that is directly related to my current treatment at VibrantCare Rehabilitation to the individual(s) listed below for purposes of their role in my treatment or payment for the health services that I have received. Such persons involved in your care may include spouses, children, blood relatives, roommates, boyfriends or girlfriends, domestic partners, neighbors and colleagues. NAME RELATIONSHIP I do not wish to have my health information disclosed to individuals involved in my care. NAME RELATIONSHIP Signature of Patient (or Patient's Representative) Date If you are the representative of a patient, check the scope of your authority to act on the patient's behalf: Power of Attorney Guardian Surrogate Decision-Maker Executor of Legal Rep. Parent Other (please specify) Provide documentation or explanation of your authority to act for the patient: Trust. Experience. Results.
11 Cancellation and No-Show Fee Your appointment is a specific time that has been scheduled for you with the VibrantCare team to work on your rehabilitation goals. It is extremely important to be timely. If you are unable to attend, YOU MUST NOTIFY THE CENTER AT LEAST 24 HOURS IN ADVANCE to reschedule your appointment. Failure to do so will result in a $25 cancellation/no show fee. Thank you for your assistance. Patient/Guardian Signature: Date: Cancelaton/No Aparecer Cobro Tu cita es un tiempo específico que se ha programado para usted con el equipo de VibrantCare para trabajar en sus metas de la rehabilitación. Es extremadamente importante ser oportuno. Si no puede atender, DEBE NOTIFICAR EL CENTRO POR LO MENOS 24 HORAS POR ADELANTADO para cambiar la hora de su cita. La falta de no notificarnos de la cancelaton/no aparecer abra un cobro de $25. Gracias por tu ayuda. Firma del paciente/del guarda: Fecha:
12 Patient Attendance Policy It is our policy at VibrantCare to give prompt, courteous service to all our patients. It is important for you to arrange your schedule so that you can be on time for these appointments. If you unable to attend or you will be late for your appointment, please notify the center in advance. We urge you to call 24 hours prior to your schedule appointment if you would like to cancel your appointment. Failure to attend your session may hinder your recovery process. If you have multiple missed appointments, your Doctor will be sent a notice. Multiple missed appointments may affect your benefits. Two or more unexcused absences (no show or cancellation without 24 hour notice) may result in discharge from therapy and/or may require appointment to your physician for a new prescription. You may be charged a fee for a no show or cancellation. If you are an industrial patient on Workers Compensation, multiple missed appointments may affect your claim. Any missed appointments will result in notification to your physician, your insurance company and/or your adjuster/case manager. I have read and understand the above. I understand that attendance at each therapy session is important to my recovery and will notify my therapist if unable to attend a session so that it may be rescheduled. Patient Signature: Date Or, Patient/Guardian Date Trust. Experience. Results.
Welcome to VibrantCare Rehabilitation Thank you for choosing VibrantCare Rehabilitation. We know you and your physician have a choice in your therapy provider and we are pleased you have chosen us. Please
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