MVA New Patient Paperwork

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1 Please Complete Entire Form MVA New Patient Paperwork Patient Name: M F Today s Date / / Address: Employer: _ City, State, Zip: Address: Home Phone: ( ) City, State, Zip: Cell Phone: ( ) Work Phone: ( ) Social Security #: Birthdate: / / How did you hear about our facility? Date of Accident: // Where did it occur: _ City: State: _ Were you the driver? Yes No If no, driver s name: If you were the driver, do you have auto insurance with PIP Coverage? Yes No If you were the passenger, does the driver have auto insurance? Yes No Name of your/driver s insurance company: Claim #: Insurance Company Address:, City:, State:, Zip: Insurance company telephone: ( ) Adjuster s Name: _ Adjuster s Phone: ( ) extension: Briefly describe the accident: Do you have an attorney at this time? Yes No If none, do you plan to retain one in the future? Yes No Attorney name: Telephone: ( ) Address:, City:, State: _, Zip: Second vehicle driver s name: Passenger Name(s): Did the driver of the second vehicle have insurance? Yes No Second vehicle auto insurance: Claim #: Address:, City:, State: _, Zip: Insurance company telephone: ( ) Adjuster s Name: _ Adjuster s Phone: ( ) extension: If you have no auto insurance or if your auto insurance benefits are exhausted or for some other reason deny claims, we will transfer billing to your health insurance to establish a subrogation account. (Subrogation is when your health insurance pays medical bills and claims reimbursement from settlement funds.) Private or Health Insurance Name: Telephone: ( ) Subscriber Name: I.D. #: _ Group #: _ Address:, City:, State: _, Zip: Relationship to subscriber: Self Spouse Dependent Other: In case of emergency, person to be notified (not living at same address): Relationship: Day Phone: ( ) Eve phone: ( )

2 Contractual Agreement Renaissance Physical Therapy Clinic Policies As a courtesy to our patients, we will prepare necessary reports and forms required for processing insurance claims/bills. You are responsible to provide relevant information so we can process these claims. You, not Renaissance Physical therapy hold the relationship with your insurance company and are therefore, ultimately responsible for their performance. According to the specific terms of your contract with the insurance carrier, you may be responsible for a portion of treatment costs. Sometimes your responsibility comes in the form of a per visit co-pay, sometimes you are responsible for a percentage of overall treatment costs. Note: If your insurance plan has a large deductible ($500 or more) Renaissance PT will collect from you at each visit a portion of the deductible until your deductible is met. It is important that you understand what your insurance will cover and what your payment responsibility may be. Renaissance Physical Therapy will issue a bill for any balance remaining after insurance payment, which you are requested to remit in full within thirty days from the statement date. If your insurance company denies payment, you are personally responsible for all outstanding charges. If you suspend or terminate your treatment at Renaissance Physical Therapy all fees for services will become immediately due and payable. Interest will be charged on all overdue accounts at the rate of 12% Apr. If your account is turned over to collection, the interest will terminate and your account will be charged a 50% one-time collection fee. By signing below, you give this office power of attorney to endorse checks made out in your name, so that they may be credited to your account. Returned checks will be subject to a $25.00 fee. Cancellation Policy If you are unable to keep your appointment, you are required to notify the clinic 24 hours in advance. Failure to provide this notice will result in a $35.00 charge to your account. This fee cannot be billed to your insurance company you are solely responsible for its payment. If you miss three scheduled appointments without appropriate notification, Renaissance Physical Therapy has the right to revoke your privileges in visiting these facilities, In such an event, your account balance becomes immediately due and payable. I certify that the information provided herein is true and correct to the best of my knowledge. I fully understand and accept all the terms of this contract, and give my signature here as testimony to this full understanding and acceptance. Patient Signature Date Patient Printed Name Parent/Legal Guardian Signature (if applicable)

3 Dear New Patient: Although it is unfortunate that were involved in a motor vehicle accident ( MVA ), we are grateful you have chosen Renaissance Physical Therapy for your Physical Therapy needs. We are committed to providing you with the best possible care. Following is some basic information regarding MVA cases and how our office will process billing. Please read it carefully and ask questions if you don t understand. First, we will bill Personal Injury Protection (PIP) portion of your auto insurance. You must have reported the accident to you insurance company, in addition to completing and returning a PIP application before your insurance company will process any claims/bills. Washington State law strictly forbids your insurance company to raise your rates based on your utilizing your PIP benefits. Your personal injury protection insurance is an arrangement between you and your insurance carrier, Renaissance Physical Therapy is not a party to that contract. Our office will prepare any necessary reports and forms for processing your insurance claims. If you do not have PIP or your PIP benefits are exhausted or denied, we will bill your private health insurance under what is called a subrogation claim. Subrogation is when your health insurance pays for medical expenses and is reimbursed at the time of settlement by the other person s auto insurance. You will need to contact your health insurance carrier to set this up with them. You will be responsible for any and all patient responsibility, deductibles, and/or co-pays that may be applicable if we have to bill subrogation through your health insurance. Ultimately, you are responsible for all charges incurred at Renaissance Physical Therapy If you have any questions regarding these policies, please do not hesitate to ask. The Accounts Receivable office is available during standard business hours to assist you at (425) ext My signature below certifies that I have read and understand these policies. It also authorizes Renaissance Physical Therapy to obtain medical records from current and previous health care providers. Patient Signature Date Printed Name of Patient Parent, Legal Guardian, Guarantor (If applicable)

4 Consent for Purposes of Treatment, Payment & Healthcare Operations I, _ (patient name), consent to the use or disclosure of my protected health information by Renaissance Physical Therapy for the purpose of providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Renaissance Physical Therapy. I understand that treatment received by a Physical Therapist may be conditioned upon my consent as evidence by signing my signature on this document. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment payment of healthcare operation of the practice. Renaissance Physical Therapy agrees to any restriction that I request, the restriction is binding on Renaissance Physical Therapy and Renaissance Physical Therapy employees. I have the right to revoke this consent, in writing, at any time, except to the extent that Renaissance Physical Therapy and its employees have taken action in reliance on this consent. My protected health information means health information, including my demographic information, collected from me and created or received by my Therapist, another health care provider, a health plan, my employer or health care clearinghouse. This protected health information related to my past, present and future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I understand that I have the right to review Renaissance Physical Therapy Notice of Privacy Practices prior to signing this document. I certify that Renaissance Physical Therapy Notice of Privacy Practices has been provided to me. The notice of privacy practices describes the types of uses and disclosure of my protected health information that may occur in my treatment, payment of my bills in the performances of health care operations of Renaissance Physical Therapy. The Notices of Privacy Practices also describes my rights and Renaissance Physical Therapy s duties with respect to my protected health information. Renaissance Physical Therapy reserves he right to change the privacy practices that are described in the notice of Privacy Practices. I may obtain a revised copy at the time of my next appointment, viewing it on the Renaissance Physical Therapy website or asking that one be sent in the mail. _ Printed Name of Patient _ Signature of Patient or Legal Guardian _ Date Relationship to Patient (i.e., Parent, Guardian, Personal Representative)

5 INTAKE HEALTH QUESTIONAIRE (This will help us understand your specific needs; please answer all that apply) PLEASE BE AS COMPLETE AS POSSIBLE Name: Date: Reason for seeking Physical Therapy: Have you had a complete medical check-up within the last year? _Yes _ No Do you now have anything contagious? _Yes _No Please check if you now have or recently have had any of the following complaints? Shortness of breath Pain or a feeling of heaviness in your chest Pulsating pain anywhere in your body Constant and severe pain in lower leg (calf) Discolored or painful feet Dizziness Persistent pain at night Constant pain anywhere in your body Unexplained weight loss Unusual lumps or growths Fatigue Frequent or severe abdominal pain Frequent nausea or vomiting Problems with swallowing or changes in speech Changes in vision (i.e. blurriness or loss of sight) Problems with balance or falling Fainting spells Problems with coordination Fever Recent severe emotional disturbances Swelling or redness in any joints

6 Are you now pregnant? _Yes _ No Please check if you have or have had: Diabetes High Blood Pressure Heart Disease Cancer Arthritis Allergies, please list: _ If you have ever had spinal surgery, please describe and give approximate dates: Please list all medications you are currently taking: What previous treatment have you received (or currently are receiving) for this injury or pain? PAIN DRAWING Mark the areas on these figures where you feel pain or sensations. Use the symbols as shown below. Indicate radiating sensations by drawing an arrow from the origin (with appropriate symbol) to its furthest point. Numbness = ### Pins & Needles = ooo Burning = xxx Stabbing = \\\ Ache = <<< Other: = +++

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