IF YOU HAVE ANY QUESTIONS, SOMEONE FROM OUR BUSINESS OFFICE WILL BE GLAD TO ASSIST YOU.

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1 WELCOME TO THE HUMAN PERFORMANCE AND REHABILITATION CENTERS, INC. Welcome to Human Performance and Rehabilitation Centers, Inc. The following information will give you a better understanding of our payment and insurance filing policies: PAYMENT POLICY: Payment is requested at the time of service unless other arrangements are made prior to treatment. We accept cash, check, MasterCard, Visa or American Express. INSURANCE: HPRC will file your primary insurance if you provide the appropriate insurance information. You will receive a statement each month if your account has a balance. You are responsible for payment of that balance. If your insurance does not pay, you should contact the insurance company. This office will not negotiate the settlement of a disputed insurance claim. MANAGED CARE CONTRACTS: HPRC is enrolled in numerous managed care and participating provider insurance programs. Please advise our staff if you are a member of this type program. All co pays or estimated patient balances are due at time of service. Our participation is not a guarantee of payment from your insurance. You will receive a statement for any balance after insurance has responded to our claim. MEDICARE: The therapists at HPRC are participating Medicare providers. We will file your Medicare and one supplement if you provide us with the appropriate insurance information. You will receive a statement each month until your account is paid out. Pay only amounts in patient responsibility on your statement. Medicare will pay 80% of covered services after your deductible is met. You are responsible for your deductible and 20% of covered charges if your supplement does not pay timely. Medicare requires that you see your physician at least every 90 days while you are receiving therapy. WORKERS COMPENSATION: Please provide HPRC with the proper information required to verify coverage. Except for acute cases, treatment will not begin until we have authorization from your workers compensation carrier. LEGAL CASES: We cannot treat patients on a contingency basis; therefore, where legal cases are pending settlement, we ask that the full charge be paid at the time treatment is rendered. IF YOU HAVE ANY QUESTIONS, SOMEONE FROM OUR BUSINESS OFFICE WILL BE GLAD TO ASSIST YOU. CONSENT FOR TREATMENT & AUTHORIZATION: I do hereby consent for treatment at The Human Performance and Rehabilitation Centers, Inc. I authorize HPRC to release medical and supporting documentation of same as compiled in my medical record during this treatment or subsequent treatments for purposes of benefit payment. I further authorize my insurance benefits to be paid directly to Human Performance and Rehabilitation Centers, Inc. when indicated on claim. I understand that I am financially responsible for the charges for services rendered. Signed Date / / Relationship to Patient: Witnessed By: (HPRC Rev. 3/2013)

2 PATIENT INFORMATION SHEET Today'sDate / / Referring Doctor Primary Care Provider What part of the body are we treating? Personal Information Name First Middle Initial Last Nickname Physical Address City State Zip Mailing Address City State Zip Home Phone ( ) Cell ( ) Work ( ) SS No: DOB: / / SEX: M F MARITAL STATUS: Married Single address (optional) Would you like to receive information from us by ? Yes No Are you disabled? Y N If yes, what is your disability? Employer Occupation Phone ( ) Spouse s Name DOB: / / SS No: Spouse s Employer Occupation Work ( ) Emergency Contact (Other than Spouse) Relationship Home Phone ( ) Work ( ) Insurance Information Primary Insurance Name of Policy Holder Policy No. Policy Holder s Phone ( ) Policy Holder s DOB / / Policy Holder s SSN Policy Holder s Address (if different): Secondary Insurance Name of Policy Holder Policy No. Policy Holder s Phone ( ) Policy Holder s DOB / / Policy Holder s SSN Policy Holder s Address (if different): If this is an approved claim through Worker s Compensation, please answer the following: Date of Injury Employer when injury occurred (if different) W/C Insurance Name Contact/Adjuster Claim No. Adjuster s Phone ( ) Please complete this section if the patient is a Minor and/or covered under parent s insurance: Mother s Name Phone ( ) SSN Address (if different) Employer Father s Name Phone ( ) SSN Address (if different) Employer Please be advised it is your responsibility to consult your insurance regarding coverage for outpatient therapy. We do check eligibility as a courtesy, but your failure to check could result in an unpaid bill for which you are responsible. Signature: / / (Rev. 3/2013)

3 ACKNOWLEDGEMENT OF NOTICE OF INFORMATION PRACTICES (To be retained by Medical Provider) I understand that Human Performance and Rehabilitation Centers, Inc. (referred to below as the clinic ) will use and disclose health information about me in the course of providing treatment. I understand that my health information may include information both created and received by the clinic, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information. I understand that the clinic is permitted to use and disclose my health information in order to: make decisions about and plan for my care and treatment; refer to, consult and coordinate with other health care providers in the course of my treatment; determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and perform various office, administrative and business functions that support the clinic s ability to provide me with appropriate care and arrange for payment. I also understand that I have the right to receive a written Notice of Information Practices that describes how the clinic uses and discloses health information, the information practices followed by the clinic staff and my rights regarding my health information. I understand that the Notice of Information Practices may be revised from time to time and that I am entitled to receive a copy of any revised Notice of Information Practices upon request. I also understand that a copy of a summary of the most current version of the clinic s Notice of Information Practices in effect will be posted in waiting/reception area. I understand that the Notice of Information Practices describes how I can exercise my right to ask that some or all of my health information not be used or disclosed, and I understand that the clinic is not required by law to agree to such requests. By signing below, I agree that I have reviewed and understand the information above and that I will be provided with a copy of the Notice of Information Practices upon request. By: (Patient) / / -OR- By: (Patient s Representative) / / Description of Representative s Authority: HPRC 07/2012

4 Patient Name: Patient/Client History Form / / How did your problem start? Date it started Where is your pain located? Foot R L Wrist R L Head Ankle R L Forearm R L Neck Knee R L Elbow R L Other Hip R L Shoulder R L Hand R L Low back R L Central Bilateral / / Rate your current pain No Pain Extreme Pain Is this with medicine? Yes No Do you have? (Mark all that apply) Yes No Difficulty falling asleep Yes Yes No Awakened by pain No Difficulty finding comfortable position Have you fallen in the last 6 months? Yes No If yes, was there an injury? What is your Occupation/Job? Current Height Current Weight What is your work status? Full Time Part Time Retired Not Working Student Modified Duty Disabled Homemaker Have you had surgery for your current problem? Yes No If yes, date of surgery / / Does your home have? Do you use? Where do you live? With whom do you live? Stairs, No Railing Cane House Alone Stairs, w/railing Crutches Apartment Spouse only Ramps Walker Assisted Living/ Spouse & other(s) Elevator Manual Wheelchair Group Home Child (not spouse) Hills Motorized Wheelchair Homeless Other Relatives Assistive Devices Hearing Aids Long term Care Group Setting (e.g. rails in bathroom) Glasses Hospice Personal Care Any Obstacles Sling Other Attendant Brace Parents Other Other Do you currently use tobacco products? Yes Cigarettes Cigars/Pipe Smokeless No Used tobacco in the past? Yes No Year quit?

5 Do you exercise regularly? Yes No What type? On average, how many days per week do you exercise? For how many minutes, on an average day? Please list your current medicines: Have you had any diagnostic tests listed below for the problem you will be treated for? If so, please check all that apply. Auditory Brainstem Response Evaluation Bone Scan EMG Swallow Study Blood Work/Lab Tests Motility Study Upper Endoscopy CT Scan MRI X Rays EEG Nerve Conduction Study Other: Have you seen any specialist / physician for this injury / problem? (Please check all that apply) Allergist ENT Internal Medicine Ophthalmologist Primary Care Audiologist Gastroenterologist Nephrologist Orthopedic Surgeon Psychiatrist Cardiologist General Surgeon Neurologist Pediatrician Rheumatologist Developmental MD Geneticist Neurosurgeon Physiatrist Thoracic Surgeon Endocrinologist Hand Surgeon Oncologist Podiatrist Urologist Please check all CURRENT medical conditions you have been diagnosed as having. Allergies Epilepsy Malaise / Fatigue Pacemaker Asthma Fibromyalgia Mental / Cognitive Disorder Pregnancy Bowel Dysfunction Headaches Metal Implants Rheumatoid Arthritis Cancer Heart condition Nausea / Vomiting Shortness of Breath Congestive Heart Failure History of smoking Neurological Disorders Syncope / Fainting Diabetes HTN / HBP Osteoarthritis Weight Change Dizziness Joint replacement Osteoporosis Have you had a recent? Hospitalization If yes, discharge date Skilled Nursing Care If yes, last visit date Outpatient Therapy If yes, last visit date Home Health Care Visits If yes, last visit date For the problem for which you will receive therapy, please list 3 things you are having pain or difficulty doing that you want to be able to do when you complete therapy (e.g. Walk up stairs, sleep through the night, tie my shoes, bathe myself, etc.) Signature Date / / (Rev. 1/2013)

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