Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081

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1 Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ PLEASE COMPLETE ALL OF THE INFORMATION. REFERRED BY: LAST NAME MIDDLE FIRST STREET ADDRESS CITY STATE ZIP CODE HOME PHONE ( ) - WORK ( ) - CELL ( ) - SOCIAL SECURITY # - - DATE OF BIRTH / / AGE SEX MARITAL STATUS: SINGLE MARRIED DIVORCED WIDOWED EMPLOYER OCCUPATION FULL TIME PART TIME RETIRED WORK ADDRESS SPOUSE S NAME SPOUSE S WORK # IF THIS IS A WORKER S COMPENSATION INJURY, PLEASE DO NOT PROVIDE US WITH YOUR PERSONAL INSURANCE INFORMATION, PLEASE FILL OUT THE INSURANCE INFORMATION ON THE NEXT PAGE. IF THIS IS A MOTOR VEHICLE ACCIDENT PLEASE FILL OUT THE INFORMATION BELOW AND ON THE NEXT PAGE. ALL COPAYMENTS ARE DUE AT THE TIME OF YOUR VISIT! PRIMARY INSURANCE ID/POLICY # ADDRESS OF INSURANCE COMPANY INSURANCE TELEPHONE # EFFECTIVE DATE OF INSURANCE SUBSCRIBER S NAME IF DIFFERENT FROM PATIENT RELATIONSHIP TO PATIENT SELF SPOUSE PARENT LEGAL GUARDIAN OTHER INSURED S DATE OF BIRTH / / INSURED S SOCIAL SECURITY # - - SECONDARY INSURANCE ID/POLICY # ADDRESS OF INSURANCE COMPANY INSURANCE TELEPHONE # EFFECTIVE DATE OF INSURANCE SUBSCRIBER S NAME IF DIFFERENT FROM PATIENT RELATIONSHIP TO PATIENT SELF SPOUSE PARENT LEGAL GUARDIAN OTHER INSURED S DATE OF BIRTH / / INSURED S SOCIAL SECURITY # - - I AUTHORIZE THE RELEASE OF ANY MEDICAL OR OTHER INFORMATION NECESSARY TO PROCESS ALL CLAIMS. DATE I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO ADVANCED REHAB SOLUTIONS FOR SERVICES RENDERED. DATE

2 PLEASE NOTE: ALL INSURANCE INFORMATION MUST BE PROVIDED WORKERS COMPENSATION INFORMATION EMPLOYER S NAME ADDRESS CITY STATE ZIP CODE TELEPHONE # OF EMPLOYER SUPERVISOR S NAME DATE OF INJURY / / LAST DAY WORKED / / ARE YOU CURRENTLY WORKING? YES NO LIGHT DUTY AS OF / / WORKER S COMPENSATION INSURANCE COMPANY NAME ADDRESS CITY STATE ZIP CODE TELEPHONE # OF INSURANCE COMPANY ADJUSTER S NAME CLAIM # MOTOR VEHICLE ACCIDENT INFORMATION INSURED S NAME INSURED S ADDRESS CITY STATE ZIP CODE DATE OF MOTOR VEHICLE ACCIDENT PLACE OF ACCIDENT INSURANCE COMPANY NAME INSURANCE COMPANY ADDRESS CITY STATE ZIP CODE ADJUSTER S NAME ADJUSTER S PHONE NUMBER POLICY # CLAIM # If we do not participate in your insurance plan, payment for service is due at the time services are provided unless other arrangements have been made in advance. We accept cash, checks and all major credit cards. We will be happy to help you complete your insurance claim form so that you may receive reimbursement from your insurance company. You will be given an invoice to submit for reimbursement. For Workers Compensation and Motor Vehicle claims, your bills will be submitted to your respective carrier for payment. Motor Vehicle claims may be subject to a deductible or co-pay amount. All Medicare claims will be submitted as assigned claims. Your Medicare claim may be subject to a deductible or co-payment. Our contract with your insurance carrier states that: ALL COPAYMENTS ARE DUE AT THE TIME OF YOUR VISIT! I understand all of the above: Signed Date

3 ADVANCED REHAB SOLUTIONS 609 Morris Avenue Springfield, NJ You have as your insurance carrier. Our office will submit this claim to your carrier for payment. Please do not submit this claim yourself. If there is any deductible or co-insurance due to our office that has not been paid, we will send you a statement reflecting this amount. You will also receive an Explanation of Benefits from your carrier describing your claim. If there are any monies due from you to this office we will bill you accordingly. Should the reimbursement check come directly to you please forward it to our office immediately. By signing this statement you agree to reimburse Advanced Rehab Solutions for any monies you receive from your insurance carrier. Responsible party signature Date

4 PATIENT CONFIDENTIALITY In this office, Patient Confidentiality is a prime concern. Please indicate below with whom our office can or cannot leave a message. Please check where appropriate. YES NO DOES NOT APPLY Spouse Parent Children Answering Machine Home Work Are you able to receive telephone calls at your work place? Yes No May we call you at your work place and state who is calling? Yes No Due to confidentiality regulations, should a family member, friend or relative contact our office, we are not at liberty to discuss your situation unless we have permission from you, the patient. Please check with whom we may discuss your situation. YES NO DOES NOT APPLY Spouse Children Parent Parent, Children, Spouse and/or Significant Others: Name Relationship Phone Name Relationship Phone

5 PAST MEDICAL HISTORY Patient Name: Please complete this form. The purpose of this questionnaire is to help us perform a thorough evaluation and to understand your condition. Please note this form is considered part of your medical records and will be kept private and confidential Have you ever suffered from or been told that you have: Heart Problems Yes No Circulation or vascular problems Yes No Cardiac surgeries/pacemaker Yes No High blood pressure Yes No Blood disorders (inc. high sedimentation rates) Yes No Diabetes (high blood sugar) Yes No Low blood sugar Yes No Head injury Yes No Stroke/neurological disorder Yes No Multiple sclerosis/parkinson s disease Yes No Hearing problems Yes No Liver problems Yes No Thyroid problems Yes No Ulcers/stomach problems Yes No Cancer Yes No Chronic pain Yes No Osteoporosis Yes No Arthritis Yes No Broken bones Yes No Other orthopedic problems Yes No Men only: Prostate disease Yes No Women only: Pelvis inflammatory disease Yes No Endometriosis Yes No Have you had complicated pregnancies? Yes No Trouble with your period? Yes No Are you pregnant or think you might be pregnant? Do you: Smoke Yes No If yes, how much? packs/day Drink alcohol Yes No If yes, how much? Have any significant family history or illness/diease? Yes No Have any other significant medical problems? Yes No Continued on next page

6 Have you recently experienced: Weight loss/gain Yes No Pain at night Yes No Fatigue/tiredness or malaise Yes No Difficulty sleeping Yes No Joint pain and/or swelling Yes No Urinary or bowel problems Yes No Nausea and vomiting Yes No Numbness or tingling (where?) Yes No Weakness in your arms or legs Yes No Coordination problems Yes No Difficulty walking Yes No Dizziness or loss of consciousness Yes No Loss of balance Yes No Chest pain Yes No Heart palpitations Yes No Shortness of breath Yes No Difficulty swallowing Yes No New onset of headaches Yes No Visual problems Yes No Have you had surgery or been hospitalized in the past? YES NO Reason and date of incident: Please list all medications you are currently taking and their dosage. If it is an extensive amount you can provide us a list and we will photo copy it and place in your chart instead. Please provide any other medical conditions we should know about that are not listed above: Who is your primary care physician or the doctor you see the most? How were you referred to us? Doctor: Friends/prior patient: Yellow pages: Online: Other:

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