Cancellation/No Show Policy

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1 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 will be required to pay this prior to your next appointment, unless other arrangements have been made. This fee cannot be billed to your insurance company; therefore you are solely responsible for payment. We have adopted this policy for the following reasons: Consistency is crucial for your success in maintaining results and progress toward achieving established goals. Multiple cancellations in your chart may be considered non-compliance for insurance related visits and may invalidate your claim making reimbursement/ settlement difficult. We try to offer appointment times that are the most convenient for our clients. Any blocked off time could have been available for others to schedule. We staff our center based on number of scheduled appointments. Thank you for taking the time to review our policy. If you have any questions, please feel free to discuss them with your Experience Momentum provider or office staff. Please read agreement and sign and date below I am aware of the cancellation policy and realize that I will be charged $50.00 for all future missed appointments not cancelled 24 hours in advance. Patient or legally authorized signature 2015 Experience Momentum Physical Therapy, Nutrition & Fitness Page 1 of 5

2 Notice of Privacy Practices This notice applies to the information and records we have about you, your health, and the care and service you receive from Experience Momentum Physical Therapy, Nutrition & Fitness (EM). This Protected Health Information (PHI) may be either created or received by EM and may be in the form of written or electronic records or spoken words, and may include information about your health history, symptoms, examinations, test results, diagnoses, treatments, procedures, related billing activity, and similar types of health-related information. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes us to do so. You may see your record or get more information about it by contacting EM. Our Notice of Privacy Practices can be found posted in the lobby of our main office, which describes in more detail how your health information may be used and disclosed, and how you can access your information. If you have any special requests to how Experience Momentum Inc. shares your information, please contact our Privacy Officer within 24 hours after your initial visit. Blake K. Stephens, DPT, FAFS: By signing below, I acknowledge receipt/review of the Notice of Privacy Practices. Patient or legally authorized signature Consent to contact you regarding the services EM provides and has provided Experience Momentum Physical Therapy, Nutrition, and Fitness is driven to always maintain the standards of the care we provide. By consenting, you are allowing us to contact you during or after your course of care regarding the services you have been provided or about other services we have here at EM for both quality improvement and in-house promotion (only within Experience Momentum Inc.). I, (printed name), give EM permission to contact me regarding the above. Consent to Leave a Message EM works to ensure that confidentiality regarding your medical information and care is maintained at all times. Because of these confidentiality concerns, we need your signature to allow us to leave a message regarding your medical care/procedure with someone in your household, on an answering machine, or voice message. I, (printed name), give EM permission to leave a message regarding my medical care on an answering machine or with an individual at the following numbers. Yes No Home Phone Cellular Other Signature 2015 Experience Momentum Physical Therapy, Nutrition & Fitness Page 2 of 5

3 General Intake Thank you for choosing Experience Momentum Physical Therapy, Nutrition & Fitness. The more we know about you, the quicker we can help you reach your rehabilitation, health and fitness goals. Please take a moment to answer the following questions. A. Client Information Name of Birth Age Male Female N/A Address City State Zip Day Phone Cellular Phone Emergency Contact Phone Parent/Guardian Name (if under 18 y.o.) Occupation Company Hrs/Wk How did learn about Experience Momentum? (circle one) Friend Self Internet Healthcare Professional Other Check this box to receive our monthly fitness, wellness, and nutrition newsletter via . B. Primary Insurance (if seeking reimbursement) Company Subscriber ID Group # Subscriber s First, MI, Last Name of Birth Relationship to the client is Self Spouse Parent Other C. Secondary Insurance (if applicable) Company Subscriber ID Group # Subscriber s First, MI, Last Name of Birth Relationship to the client is Self Spouse Parent Other As a complimentary service, we will bill your insurance company for you. Once we receive payment from your insurance provider, any patient responsible portions will be billed to you directly. Copays are due at time of service. Note you may be subject to annual deductibles. It is in your best interest to contact your insurance company to verify your benefits for Physical and Massage Therapy. I authorize my insurance benefits to be paid directly to Experience Momentum Inc. I understand I am responsible for any balance due, attorney or collection costs for services rendered not covered by my insurance due to lack of prior authorization or written referral. I authorize the release of medical information required for my claims to be processed. This may include information regarding diagnosis or treatment of HIV, STD s, drug or alcohol use or abuse, mental illness, or psychiatric treatment. Interest or penalties may be charged. I authorize Experience Momentum Inc. to contact the Insurance Commissioner to aid in receiving payment if necessary. Signature (Parent or guardian if under 18) 2015 Experience Momentum Physical Therapy, Nutrition & Fitness Page 3 of 5

4 Massage Therapy Intake General Symptoms Description Who may we thank for referring you? Describe your current condition: How did the condition begin? When did the condition first present? What makes the condition better? What makes the condition worse? Are you currently or have you previously received any treatment(s) for this condition? Yes No If yes, please explain: Specific symptom(s) description How severe is your pain (circle) No pain Unbearable pain How often are your symptoms present? Describe your current symptoms/ pain (Circle all that apply) Tingling - Numbness - Burning - Soreness - Shooting - Throbbing - Dull/ Achy - Sharp/ Stabbing Can you perform daily activities? (circle) without pain Severe pain How does your current condition influence your quality of sleep (circle) no effect significant effect What goals do you hope to achieve with massage therapy? Symptoms Location Please rate your level of stress (circle) mild Severe Please circle areas of pain, tingling, numbness, burning, soreness or tension Notes: Continue to next page 2015 Experience Momentum Physical Therapy, Nutrition & Fitness Page 4 of 5

5 Health History Have you had any of the following conditions? Musculo-Skeletal Circulatory/ respiratory Endocrine Bone or Joint disease Tendonitis Bursitis Broken/ Fractured bones Joint dislocation arthritis sprains/strains low back, hip, leg pain neck, shoulder, arm pain Headaches/ head injuries Spasms/ Cramps Joint bone or muscular surgeries Fibromyalgia Skin Allergies rashes Eczema Sensitive skin Heart Condition Varicose veins blood clots high blood pressure low blood pressure lymphedema breathing difficulty asthma sleep apnea Reproductive Pregnant (week) Nursing (weeks postpartum) Severe or unusual PMS Erectile dysfunction Enlarged Prostate Immune/autoimmune Rheumatoid Arthritis Chronic Fatigue Syndrome I understand that clinical massage/bodywork is for the purpose of relaxation, stress reduction, and relief from muscular HIV/Aids tension through manipulation of soft tissue. It is not for the cause of diagnosis or prescription, and it does not replace the need for proper self-care. I understand that while massage therapy may at times be uncomfortable it should not be painful and that it is my responsibility to notify my Massage Therapist if the pressure needs to be decreased. Because massage should not be performed under certain conditions, I affirm that I have stated all my known medical conditions and answered all questions truthfully. I agree to keep my Massage Therapist updated on any changes to my medical profile I confirm that the information I have provided is correct to the best of my knowledge Diabetes (type) Hyperthyroid Hypothyroid Cancer Other Psychological disorder mental disability Bipolar/ Depression Drug/ Alcohol addiction Epilepsy Seizure Parkinson s disease Current Medications: Patient Name: Patient Signature: _ : 2015 Experience Momentum Physical Therapy, Nutrition & Fitness Page 5 of 5

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