DEL MAR PHYSICAL THERAPY Patient Information

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1 PLEASE PRINT CLEARLY DEL MAR PHYSICAL THERAPY Patient Information Name Birthdate Last First M.I. MM/DD/YYYY Age Sex M / F Marital Status SS# Address City Zip Phone ( ) Work ( ) Cell ( ) ********************************************************************************** Emergency Contact Relationship Phone ( ) Was Injury Personal Accident Yes / No Auto Related Yes / No Employment Related Yes / No Prior Physical Therapy THIS YEAR: Yes / No If YES please indicate: Last date of treatment # of Visits Facility Name/Location Ph ( ) Are you currently receiving / received in the last 30 days Home Health from anyone for any procedure? Yes / No Agency Contact Phone ( ) ********************************************************************************** Responsible Party Information (if other than above or Minor under 18yrs) Name Employer D.O.B. Relationship to Patient Address City: Zip: SS# Phone ( ) ********************************************************************************** Referred By

2 DEL MAR PHYSICAL THERAPY FINANCIAL POLICIES AND BILLING PROCEDURES AUTOMOBILE ACCIDENT CLAIMS Thank you for choosing Del Mar Physical Therapy for your physical therapy services. Please be aware that Del Mar Physical Therapy is a separate organization from the physician who referred you to us for treatment. As a courtesy to our patients, we will bill approved Auto Insurance companies. All necessary billing information must be supplied on or before your initial appointment. This includes a completed insurance information form with proof of a claim number, adjuster s name and phone number and a prescription from your physician. You have a direct contract with your Auto Insurance with which we are not a party. In most cases, patients have Med Pay which covers their visits up to a specific amount. Treatments beyond the Med Pay amount will be billed to the patient. We make every effort to track the Med Pay limit but ultimately it is the responsibility of the patient. Del Mar Physical Therapy cannot bill third party claims so if you have no Med Pay coverage we will not be able to bill the auto insurance company of the other party involved in your accident. 24 hour notice must be given for cancellation of scheduled appointments. Failure to do so will result in a $30.00 cancellation fee which must be paid by your next appointment. This fee cannot be billed to any insurance. Accounts with outstanding balances are reviewed and processed by Green Profit Recovery for collection. We reserve the right to change or cancel any appointment as is necessary. On these occasions, every effort will be made to reschedule you at your convenience. I have read and understand the above policies and procedures. Patient Signature th Street, Suite B, Del Mar, CA (858)

3 ASSIGNMENT AND DIRECT PAYMENT Primary Insurance Information Circle One: Worker s Comp Private Insurance Auto Insured s Name Policy# D.O.B. Insurance Co. Name Group# Subscriber/relation HMO / PPO / POS / EPO In Network Benefits Deductible $ Calendar Year: Yes / No Deductible Met $ O/O/P $ Met $ CoPay $ Ins. Pays % Co-Ins % Referral Required? Yes / No Max Visits per Yr #Visits used to Out of Network Benefits Deductible $ Calendar Year: Yes / No Deductible Met $ O/O/P $ Met $ CoPay $ Ins. Pays % Co-Ins % PreCert Required? Y / N Max Visits per Yr #Visits used to I hereby instruct and direct that the above stated insurance company remit payment directly to: Del Mar Physical Therapy th Street Del Mar, CA or If my current policy prohibits direct payment to the therapist, I will hereby instruct and direct the insurance company to make out the check to me and mail as follows: C/O Del Mar Physical Therapy th Street Del Mar, CA THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER MY POLICY. The payment issued by my insurance company to provider will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay in a timely manner, any balance of any and all professional service charges over and above the insurance payment and my benefits have been explained to me. A photocopy of this Assignment shall be considered as effective and valid as the original. I also authorized the release of any information pertinent to my case to any insurance company, adjuster or attorney involved in this case. I authorize therapist to file complaints directly to the California Insurance Commissioner, if the need arises. Signature of Policyholder Signature of Claimant (if other than Policyholder)

4 Del Mar Physical Therapy PATIENT INFORMATION ACKNOWLEDGEMENT FORM I have read and fully understand Del Mar Physical Therapy s Notice of Information Practices. I understand that Del Mar Physical Therapy may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I also understand that Del Mar Physical Therapy will consider requests for restriction on a case by case basis, but does not have to agree to requests for restrictions. I hereby consent to the use and disclosure of my personal health information. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time. Patient Name Signature

5 INSURANCE BILLING INFORMATION Are we seeing you due to: (please check if any apply) Work-related injury Home-related accident Auto accident What is the date of your injury? What is the name of your insurance company? Do you have a claim number? Yes No If you answered yes, please enter your claim number here: Adjuster s Name Phone number Insured s Name Relationship How would you like us to bill for your treatment? Workers Compensation Private Insurance Bill you personally Automobile Insurance Medicare Please give us a brief description of your accident, including when, where and how it happened:

6 PATIENT HISTORY Please complete this questionnaire prior to your appointment. NAME: AGE: DATE: PHYSICIAN: OCCUPATION: MEDICAL HISTORY Please check if you have had any of the following: Advice from MD not to exercise Arthritis Back Injury Bladder/ Bowel Dysfunction Breathing Problems Cancer Circulation Problems Cold Hypersensitivity Dermatitis, Rashes Diabetes Dizzy Spells Eye Problems Fever (currently) Frostbite (area of the body) Fractures Headaches (recurrent) Heart Problems High Blood Cholesterol High Blood Pressure HX of Heart Disease before 55 Malignancies Motor Vehicle Accident Nerve Damage Osteoporosis Pregnancy (last 3 months) Raynaud s Disease Respiratory Problems Seizures Stroke Swelling Tingling/ Numbness Whiplash medical problems Have you ever had any surgeries? When? Name of Surgery When? Name of Surgery Do you have any metal in your body (other than in your teeth)? Yes No Do you have a cardiac (heart) pacemaker? Yes Do you have trouble with your vision? Yes No No List any allergies you have List any medications you are now taking: Have you ever had any physical therapy treatments before? Yes No If yes, indicate when and condition treated Do you have, or have you had in the past, any of the following that would affect your current condition? Pain, injury, fracture or sprain to: Ankles Back Buttocks Elbow Fingers Forearm Head Hip Jaw TMJ Neck Shin Shoulder Wrist Knees If so, please explain Describe briefly the history of your present accident or illness

7 Patient Health Questionnaire - PHQ ACN Group, Inc. - Form PHQ-202 ACN Group, Inc. Use Only rev 7/18/05 Patient Name 1. Describe your symptoms a. When did your symptoms start? b. How did your symptoms begin? 2. How often do you experience your symptoms? Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) Indicate where you have pain or other symptoms 3. What describes the nature of your symptoms? Sharp Dull ache Numb Shooting Burning Tingling 4. How are your symptoms changing? Getting Better Not Changing Getting Worse 5. During the past 4 weeks: a. Indicate the average intensity of your symptoms None Unbearable b. How much has pain interfered with your normal work (including both work outside the home, and housework) Not at all A little bit Moderately Quite a bit Extremely 6. During the past 4 weeks how much of the time has your condition interfered with your social activities? (like visiting with friends, relatives, etc) All of the time Most of the time Some of the time A little of the time None of the time 7. In general would you say your overall health right now is... Excellent Very Good Good Fair Poor 8. Who have you seen for your symptoms? No One Chiropractor Medical Doctor Physical Therapist a. What treatment did you receive and when? b. What tests have you had for your symptoms and when were they performed? Xrays MRI CT Scan 9. Have you had similar symptoms in the past? Yes No a. If you have received treatment in the past for the same or similar symptoms, who did you see? This Office Chiropractor Medical Doctor Physical Therapist 10. What is your occupation? Professional/Executive White Collar/Secretarial Tradesperson Laborer Homemaker FT Student Retired a. If you are not retired, a homemaker, or a student, what is your current work status? Full-time Part-time Self-employed Unemployed Off work Patient Signature

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