How To Get A Physical Therapy At West Point Physical Therapy Center
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- Adrian Evan Roberts
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1 Palmdale (Main) 1115 West Ave. M-14 Palmdale, CA (661) To our workers compensation patients: Cathedral City Perez Rd., Ste. H6-H7 Cathedral City, Ca (760) California City 9300 N. Loop Blvd. California City, CA (760) Rosamond 1431 Rosamond Blvd. Ste. 11 Rosamond, Ca (661) Welcome to West Point PT Center, Inc. During your stay here with us, we will be working on your rehabilitation so that you may return to your regular work duties. We would like to bring to your attention a few items that will help your treatment benefit you. 1. All prescriptions for therapy must be completed in a timely manner. You are given a one week extension to complete missed visits. 2. Missed visits that are not made up will be reported to your claims adjuster. 3. You should complete all visits that the doctor prescribes for you, unless he/she orders for you to discontinue the treatment, in which case, please contact us immediately to cancel any further appointments. 4. If at any time during your treatment you feel that you do not need more therapy, please tell the physical therapist on duty so we may re-assess your condition and make a determination; then proceed to follow-up with you doctor so that he/she may make the final decision. 5. To insure the maximum benefit of physical therapy, it is imperative that you attend all your treatments as ordered by the physician. Breaks or gaps in treatment may and can cause regression in your improvement. If you have any questions concerning your workers compensation claim, please ask for our workers compensation coordinator at any time. Indio Dr. Carreon Blvd. Ste. A104 Indio, CA (760) Thank You, West Point PT Center, Inc.
2 PATIENT INFORMATION Name: : DOB: Sex: M / F S.S.#: D.L.#: Address: City: State: Zip: Phone #: Cell #: Employer Name: Address: Phone#: City: State: Zip: Referring M.D.: Accident Related: Y / N Work Related: Y / N of Injury: Workers Compensation Insurance: Attorney Name: Phone #: Primary Insurance: Secondary Insurance: Assignment and Release I, the undersigned, have Insurance Coverage with and assign directly to West Point Physical Therapy all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize West Point to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions. Signature of Insured/Guardian Medicare Authorization (Medicare Patients Only) I request that payment of authorized Medicare benefits be made either to me or on my behalf to West Point Physical Therapy for any services furnished me by West Point. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I understand that with my signature, payment may be made and authorizes release of medical information necessary to pay the claim. If "other health insurance" is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the Physical Therapist or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and noncovered services. Coinsurance's and deductibles are based upon the charge determination of the Medicare carrier. Beneficiary Signature
3 PATIENT HISTORY INFORMATION Patient Name Last First Middle Initial Age Height Weight Occupation Of Injury Do you do heavy lifting at work? Are you right or left Handed? List all the current medications being taken right now? List the Allergies that you May Have Please Place a check in the box if you have been treated for or have a history of the following: Heart Disease Lung Disease High Blood Pressure Mental / Emotional Problems Seizures Circulatory Problems Ear Problems Stroke Eye Problems Skin Problems Recent Fractures Cancer Numbness/Tingling Pacemaker Diabetes I have not been treated for any of the above listings Please explain all of the above checked items. Do you have any metal in your body? Explain Are you pregnant? Signature Signature
4 Palmdale (Main) 1115 West Ave. M-14 Palmdale, CA (661) Cathedral City Perez Rd., Ste. H6-H7 Cathedral City, Ca (760) INSURANCE ELIGIBILITY WAIVER I understand that if my eligibility for insurance coverage is not established for any service received from West Point Physical Therapy Center, Inc., I or the person financially responsible for me will assume full responsibility for all charges incurred by myself, and pay in full all such charges. NOTICE OF APPOINTMENT CANCELLATION, NO-SHOW & LATE POLICY California City 9300 N. Loop Blvd. California City, CA (760) I understand that West Point Physical Therapy Center, Inc., requires that any appointment cancellation notice be given 24 hours prior to the scheduled visit, otherwise it will result in the loss of the visit. I further understand that if I do not show up for two consecutive appointments, without contacting West Point Physical Therapy Center, Inc., it will result in an automatic discharge. Rosamond 1431 Rosamond Blvd. Ste. 11 Rosamond, Ca (661) I also understand that if I arrive 15 minutes late or more to my scheduled appointment, I forfeit my visit and will not be seen until my next scheduled appointment. NOTICE OF POLICY PRACTICE Indio Dr. Carreon Blvd. Ste. A104 Indio, CA (760) I was supplied with West Point Therapy Center s notice of privacy practice, I have read it and understand it s contents. Furthermore, I understand I am entitled to a copy of the original document, which I can ask for at any time.
5 WORKERS COMPENSATION INFORMATION FORM : Name: Last First Employer: Reporting Supervisor: DOB: of Injury: of Injury: W/C Insurance Co.: Address: Claim #: Phone #: ( ) - City: State: Zip: Adjuster: Describe your injury: Injured Body Part: Do you have an attorney because of this work related accident? Y / N Attorney: Phone #: ( ) - Address: Is this claim: Accepted Denied Litigation Delayed West Point Physical Therapy Center, Inc. Would like to take the time to thank you for filling out this form. This information will expedite your authorization for treatment process.
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X Guarantor/Parent/Guardian Signature
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New Patient Registration Information
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Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,
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Personal Information Today s : Patient First Name: Initial: Last Name: DOB: Age: Social Security #: E-mail: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Gender: M F Language: ENGLISH
Dr. H. Lokesh M.D Dr. R. Desai M.D Tarah Savino MMS, P.A. C 4804 Rowan Road New Port Richey, FL 34653 (727) 375 5242 (727) 375 5198 Fax
Practice Policies for Patients It is important to read all the enclosed information carefully. Confirmation and Cancellation of Appointments: Our patients are very important to us. Missed appointments
New Patient Intake Package
CORE Physical Therapy 1255 S State St, Suite 7 Dover, DE 19901-6932 Phone: (302) 734-0100 Fax: (302) 734-0101 New Patient Intake Package - Welcome Letter - Consent Form - Appointment Contact Preference
Hands-On Care Physical Therapy P.C PhysioCare Physical Therapy P.C EXPLANATION OF PROCEDURES
EXPLANATION OF PROCEDURES Welcome to our practice. You are here because you have been referred to us by your doctor for Physical Therapy. Physical Therapy is defined as: The evaluation, treatment or prevention
DOB: // // Gender: Male Female. Home: Cell: Work:
Core Physical Therapy Clinics, LLC Paper Registration Form Patient Name Date DOB: // // Gender: Male Female Address: City State: Zip Code Home: Cell: Work: Email: Emergency Contact Employer: Name Insurance
WELCOME TO TRI-COUNTY EYE CLINIC
WELCOME TO TRI-COUNTY EYE CLINIC Thank you for choosing Tri-County Eye Clinic as the provider for your eye care. You have an appointment at one of the following two locations: 15122 Dedeaux Road, Gulfport,
INJURY INFORMATION WORSHEET
APPENDIX A INJURY INFORMATION WORSHEET PATIENT INFORMATION Patient Name Contact Phone Today s DOB DOI HEALTH INSURANCE - PRIMARY Insurance Co. Name of Insured Benefits Phone# Insured SS# Insured DOB Policy
PATIENT /GUARDIAN SIGNATURE
PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: Date: / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S. #: - - Home Phone: ( ) - Alternative Phone (Cell, Pager):
Life is Beautiful. See it! New Patient. Dr. Mr. Mrs. Ms. First name. Last name. Street address. Home Phone Cell Phone Work Phone
9201 Sunset Boulevard Suite 709 West Hollywood, CA 90069 New Patient 310. 275. 5533 Fax 310. 275. 5523 info@benjamineye.com www.benjamineye.com Patient Information Title Dr. Mr. Mrs. Ms. Sex M F Patient
P.S. Please remember to bring your completed forms to your office visit!
Dear Patient: Please print the following forms and complete them as accurately as possible and bring them with you to your office visit. If you have any questions about the forms you can call my office
Preferred Pharmacy: Phone: Fax:
PATIENT INFORMATION: TODAY S DATE Last Name: Date of Birth: Sex: Male Female First Name: SS#: Middle Initial: Marital Status: Street Address: City: State: Home Phone: Work Phone: Mobile Phone: Email: Contact
HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME
HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME We are pleased you have chosen us for your physical therapy needs. Our office is committed to providing
MVA/ PI Registration Form. Is this accident work related? YES or No If yes, stop here and notify front desk for different forms.
MVA/ PI Registration Form Is this accident work related? YES or No If yes, stop here and notify front desk for different forms. Date: Patient # Patient Name: DOB; Gender: M or F SSN Address: City/State:
Patient Information. Claims Address: Please also provide Health Insurance information in addition to Work Comp /Auto
For Office Use Updated By (Initial Here): Mailing Address: Patient Information City, State & Zip: Primary Home Cell Permission to Leave Messages: Yes No Secondary Home Cell Permission to Leave Messages:
Optimum Performance Physical Therapy, LLC
Optimum Performance Physical Therapy, LLC Patient Information: Name: DOB: SS# Address: Phone: (H) (W) (C) Sex: Male Female Marital Status: M S D W Email: Employer Name/ Address: Referring Physician: (P)
HEALTH INSURANCE INFORMATION (Please provide copies of all insurance cards) PRIMARY INSURANCE POLICY # GROUP # PHONE #
PATIENT INFORMATION LAST NAME FIRST NAME MI (PLEASE PRINT) ADDRESS CITY STATE ZIP CODE HOME # CELL # WORK # DATE OF BIRTH SEX SOCIAL SECURITY # MARTIAL STAUS REFERING PHYSICIAN/ PRIMARY CARE PHYSICIAN