New Patient Registration Information
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1 New Patient Registration Information
2 ADAMS COUNTY LOCATIONS YORK COUNTY LOCATIONS Adams Health Center (717) Apple Hill (717) Aspers Health Center (717) Bannister Street (717) Deatrick Commons (717) Queensgate Towne Center.... (717) Fairfield Town Center (717) Shrewsbury (717) Herr s Ridge (717) SPORT Center Hanover (717) Wheatlyn (717) York Hospital Pediatrics (717) Welcome! Thank you for choosing WellSpan Rehabilitation for your therapy needs. We have a team of dedicated therapists who make high quality, personalized care a top priority. There are several forms you will need to complete prior to your initial evaluation with the therapist. Please assist us in our efforts to serve you efficiently by arriving 20 minutes before your scheduled appointment to allow for completion of these forms. In addition, this provides our administrative staff the needed time to prepare your chart. These steps will ensure that your therapist has more time to spend with you. 1. Medical History ~ Please complete the medical history form thoroughly. If the question does not apply to you, fill in N/A. The therapist will review this form with you, but to guarantee a comprehensive view of your overall health, we need all of this information to guide us in your plan of care. 2. WellSpan Rehabilitation Outpatient Services Consent & Authorization Form ~ Please read, sign, and date this form. If the patient is a minor, the parent or legal guardian authorizing consent must sign. For your benefit and convenience, we also provide the following toll-free number to complete your registration in advance of your initial rehabilitation appointment. Please call and a call center representative will be happy to assist you. It is advised that you have insurance information available when you call. You may also pre-register for your appointment at REHAB NO SHOW/CANCELLATION POLICY We strive to deliver the best possible outcome for all of our therapy patients. In order for you to feel better as quickly as possible, your attendance and follow through must be consistent and regular. If you are unable to keep a scheduled appointment, we ask that you contact us at least 24 hours prior to your appointment. Please note, it is our policy that if you miss three consecutive appointments without notice, you will be discharged. In order to return to therapy, you must obtain a new referral from your doctor. INACTIVE ACCOUNTS If your account is inactive for two weeks or more, it will be considered for discharge. To avoid discharge, it is important that you communicate with your therapist if there is a necessary lapse in your treatment.
3 BILLING AND INSURANCE INFORMATION We present the following insurance and billing information to make you aware of your financial responsibilities as a patient. Please review carefully. INSURANCE If your insurance plan requires you to have a referral from your primary care physician and this is not secured, you may be responsible for services provided until one is obtained. We do participate with many insurance companies. Please ask if you are unsure if we participate with yours. 1. Certain services may not be covered depending on your particular plan of care. You need to contact your insurance company with any questions about what they will cover. 2. If you have been advised of a noncovered service and you choose to proceed with treatment, you will be asked to sign a waiver indicating you are financially responsible. If your visit is related to workers compensation or automobile insurance, and you do not have health insurance coverage, you will be asked to sign a waiver agreeing to pay the balance of charges for all services provided by WellSpan Rehabilitation that are not paid by Workers Comp or Auto Insurance. If you do have health insurance coverage you are required to provide this information to our front office staff. This is necessary for several reasons: 1. If benefits expire on the workers comp or auto claim, balances may then be submitted to your health insurance for consideration. 2. If you choose to withhold your regular health insurance information, you will be asked to sign a waiver and assume responsibility for balances incurred. 3. In addition, providing us this information will allow authorizations to be obtained and in place, if necessary, for proper benefit coverage. You are responsible to let us know of any insurance changes immediately. We cannot be responsible for costs you may incur due to a change in benefits, particularly if we are not aware of the change. BILLING Billing for WellSpan Rehabilitation is done through Wellspan Health. They will send a bill to your insurance company for all services provided in our offices. Please note 1. If a patient balance (copayment or deductible) remains after your insurance processes the claim, you will be billed. Statements will be sent on a monthly basis. Payment of your bill is expected upon receipt. 2. Any bill not paid by the due date will be forwarded for collection proceedings. 3. If you need assistance or are having financial difficulty, we urge you to contact a Customer Service Representative who can advise you. They may be reached at
4 MEDICAL HISTORY Name: DOB: Phone: (Home) (Work) (Cell) Preferred DAYTIME contact # Next appointment with referring doctor ARE YOU CURRENTLY RECEIVING HOME HEALTHCARE? Y or N List Agency PREVIOUS THERAPY: Please check which applies to you. ( ) I have NOT had previous outpatient physical/occupational therapy for ANY condition this year. ( ) I HAVE had previous outpatient physical/occupational therapy for ANY condition this year. ALLERGIES REACTIONS TO MEDICINE PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING: Do you have a pacemaker, defibrillator, or any other similar implant? Y or N Date of Injury If none specific, please provide the date you saw the doctor and were referred for treatment Physician(s) following you for this problem (please provide name and phone number) Dr. Phone Dr. Phone How did your injury occur? Accident at work Accident at home Sports injury Car Accident Unknown injury Other (specify) What medical tests have you had related to this condition? (please check) X-rays Bone Scans MRI CAT scan None Please list any previous injuries and/or surgeries: What is your occupation? Currently working? Y or N If so, list any work restrictions: Are you on disability in relation to this problem? Y or N Medical Illness History: Please circle all those that apply. thyroid disease pancreatitis diabetes seizures emphysema stroke blood clot anemia ulcers arthritis hepatitis hearing loss chest pain hiatal hernia heart problems tuberculosis asthma cancer blood pressure depression prostate problems kidney stones current pregnancy head trauma/concussion migraine headaches epilepsy/seizures/convulsions fracture joint dislocation osteoporosis back/neck injuries circulatory problems *Do we have your permission to leave a message on your answering machine? Y or N *Other than physicians involved in your care, is there anyone else we can speak with regarding your treatment? Y or N *Please list Patient signature Date Revised 03/2013
5 WELLSPAN REHABILITATION OUTPATIENT SERVICES CONSENT & AUTHORIZATION FORM TREATMENT, PAYMENT & BUSINESS OPERATIONS Consent for Medical Treatment: I hereby consent and authorize Wellspan Rehabilitation Outpatient Services, its agents, and employees, to the administration of medical care, including, but not limited to, routine diagnostic tests/procedures and such medical treatment as considered to be necessary by the ordering/attending physician, and/or his/her designee. I further understand that the physicians furnishing the services may be independent contractors who have been granted privileges or may be employees or agents of Wellspan Rehabilitation Outpatient Services. Wellspan Rehabilitation Outpatient Services cannot be held responsible for the acts of physicians who are independent contractors of the Wellspan Rehabilitation Outpatient Services. I understand and have no objection to physicians in training or other hospital approved persons assisting in or observing my treatment when the purpose is to advance medical education. Medicare Authorization: Patients Certification Authorization to Release Information and Payment Request : I certify that the information given to me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. Medical Assistance Recipient Statement: I certify that the information is true, correct and accurate. I understand that payment and satisfaction of this claim will be from Federal and State funds that any false claims, statements or documents or concealment of material facts may be prosecuted under applicable Federal and State laws. Financial Agreement: The undersigned, in consideration of the services to be rendered to the patient, is obligated to pay Wellspan Rehabilitation Outpatient Services in accordance with it s regular rates and terms and, if the account is referred to an attorney or agency for collection, to pay reasonable attorney s fees, collection expenses, court costs and other necessary and appropriate expenses incurred in collecting for services. The undersigned agrees to be responsible for charges not covered by insurance. It is understood that the obligation to pay Wellspan Rehabilitation Outpatient Services may not be deferred for any reason, including legal actions against other parties to recover medical costs, and I consent to the release of information required for billing and collecting from third party payers. Assignment of Benefits: I hereby assign to Wellspan Rehabilitation Outpatient Services all medical and insurance benefits payable to me under the health insurance carrier(s). I understand that I am financially responsible for the charges not covered by this assignment. My signature represents my acknowledgement of reading and understanding the statements. I have carefully read and understand this consent, authorization, and financial agreement, and accept the terms as initialed. Signature of Person Authorized to Consent Relationship to Patient Date Witness Revised 3/2013
Medical History Questionnaire
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Orthopedic Initial Questionnaire. Date: Weight:
Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
Orthopedic Initial Questionnaire
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PATIENT REGISTRATION
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X Guarantor/Parent/Guardian Signature
Patient Name: Last First Address City State Zip Phone# (C) (H) (W) Date of Birth Social Security# (REQUIRED FOR BILLING) If Patient is a Minor, a Parent s Name & Social Security# are Required Emergency
Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:
Patient Information Referred By: Referring Physician: Patient Name: Appointment Date: Time: Last First Middle Int. Date of Birth: SS#: Street Address: City/State/Zip: Phone Numbers: Home: Work: Cell: Email:
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Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,
Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia
Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
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Consent for Care and Treatment I, the undersigned, do hereby agree and give my consent for HAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C., to provide Care and Treatment to considered necessary
WELCOME PATIENT CONDITION
NATURAL CARE WELLNESS CENTER 6 SEELEY LANE, ELIOT, ME 03903 WELCOME PATIENT CONDITION PATIENT INFORMATION Date Reason for Visit SS# Patient Name Last Name First Name Middle Initial Address Do you suffer
LOUISIANA PHYSICAL THERAPY CENTERS OF PINEVILLE, LLC 1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527
1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527 Patient Information Name First Middle Last Address City State Zip Phone Other Contact Email Social Security # DOB
Stonebridge Adult Medicine, P.A. Registration Form (Please Print)
Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female
PATIENT INTAKE AND CONSENT FORM
PATIENT INTAKE AND CONSENT FORM Attachment B1.003A Attachment M7.005C Internal Use Only: A/C# Name A/C Type Office# First Name Last Name City State Zip Responsible Party City Phone Number Relationship
Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Last Name First Name Middle Initial Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Home Phone ( ) Mobile
460 Main St, East. Unit M3 Hamilton, ON L8N 1K4 T: 905 524 3709 F: 905 524 4866 info@physiotherapyclinic.ca
Page 1 of 6 Date Patient Information (Please complete all fields below) Last Name First Name Intl. Street Address Home Tel. City/Town Province Postal Code Work Tel. Date of Birth (mm/dd/yyyy) Gender M
3 Emergency Contact. Eaton Chiropractic & Rehab Center. 1 Patient Information. 2 Insurance / Guarantor. 4 Accident Information. Emergency Contact:
Eaton Chiropractic & Rehab Center 1 Patient Information Name: First Initial Last Address: Home: Work: Cell: DOB: Male Sex: Female SSN: Email: Single Divorced Marital Status: Married Separated Widowed Full
PATIENT INFORMATION. Phone: Cell Phone: _ Work phone: Email Address:
NEW HAMPSHIRE GASTROENTEROLOGY, INC. 9 Washington Place, Suite 204, Bedford, NH 03110 Office: 603-625-5744 Fax: 603-606-3049 ** Please return this form completed ASAP** PATIENT INFORMATION Name: DOB: DATE:
Patient Information Sheet
27071 Cabot Rd., #101 Laguna Hills, CA 92653 (949) 588-7278 (949) 588-7331 Fax Patient Information Sheet [ ] Cash [ ] Insurance [ ] Medicare [ ] Personal Injury [ ] Auto Accident [ ] Workers PATIENT NAME
THE EYE INSTITUTE. Dear Patient:
THE EYE INSTITUTE Eye Associates of Wayne P.A. 968 Hamburg Turnpike Wayne, NJ 07470 p. 973-696-0300 f. 973-696-0464 Eye Institute North, LLC 5677 Berkshire Valley Rd. Oak Ridge, NJ 07438 p. 973-208-0600
Do you have private medical insurance (i.e. Blue Cross, Sun Life, Great West Life)? Yes
PERSONAL INFORMATION: The information in this section has remained unchanged from my last visit with CORE Physiotherapy & Rehabilitation Centre Inc. Last Name: DOB: First Name: Health Card Number: Address:
Next Level Physical Therapy PC Patient Information
Next Level Physical Therapy PC Patient Information First Name M.I. Last Name Date of Birth SS# (if minor, leave blank) Student? F/T P/T NO Street Address Billing Address (if different) City State Zip Home
ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION
Outpatient Services 2381 Lawrenceville Road 609-896-9500 voice Patient Name: Account #: ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Your first day of outpatient
LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP OCCUPATION EMPLOYER/SCHOOL WORK PH
PLEASE PRINT PATIENT INFORMATION TODAY S DATE: LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP E-MAIL HOME CELL OCCUPATION EMPLOYER/SCHOOL WORK SOCIAL SECURITY NO SEX: M / F DATE OF BIRTH MARITAL STATUS:
CARSON PHYSICAL THERAPY, INC.
PATIENTS WITH WORKER'S COMPENSATION INSURANCE We are interested in providing you with the best and most effective care possible. In order to begin your Physical Therapy as soon as possible, we offer you
Personal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
PATIENT REGISTRATION Must complete entirely. Reason for today's visit: New Patient: Y N Existing Patient: Y N. Date of Birth: Age:
Anthony N. Dardano, D.O., P.A., F.A.C.S. AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY Diplomate of the American Board of Plastic Surgery Diplomate of the American Board of Surgery 951 N.W. 13 th Street,
Welcome To Pace Physical Therapy
Welcome To Pace Physical Therapy Please take a few minutes to fill out the following registration forms prior to coming to your appointment. This will allow your physical therapist more time to attend
MEDICAL-SURGICAL EYE CARE, P.A.
MEDICAL-SURGICAL EYE CARE, P.A. DATE PATIENT'S NAME: ADDRESS: CITY/STATE/ZIP: DATE OF BIRTH: MARTIAL STATUS: M S D W HOME PHONE: ( ) SEX: M F AGE: CELLPHONE: ( ) IF CHILD; PARENT OR GUARDIAN NAME: EMERGENCY
HI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy)
HAWAII PHYSICAL THERAPY INC. -- PATIENT REGISTRATION FORM Please fill out this form to register as a patient of Hawaii Physical Therapy Inc. All fields with an asterisk (*) are REQUIRED. We cannot register