FAIRBANKS PHYSICAL THERAPY
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- Howard Gregory
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1 REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you have provided all necessary information and signatures. The process should take no more than 15 to 20 minutes: PRINT pages 2 through 4 READ pages 5 and 6 COMPLETE the New Patient Registration Form (page 2), including o Section I, New Patient Information o Section II, Billing and Payment Information o Section III, Initial and Sign after reading pages 5 and 6 COMPLETE the Health History Form (pages 3 and 4) CALL your insurance company using the guide on page 7 to learn about your policy s physical therapy benefits BRING the printed forms, your photo ID, and any insurance cards(s) with you to your first appointment.
2 NEW PATIENT REGISTRATION FORM SECTION I: NEW PATIENT INFORMATION First Name: Middle: Last Name: (OFFICE USE ONLY): Date of Birth: SSN: Address: City: State: Zip: Home Phone: Work Phone: Mobile Phone: Emergency Contact: Relationship: Phone: SECTION II: BILLING AND PAYMENT INFORMATION Primary Health Insurance Company (if none, enter SELF ): Name on policy: Policy-holder s DOB and SSN (if not yourself): Secondary Health Insurance Company (if applicable): Name on policy: Policy-holder s DOB and SSN (if not yourself): Auto, Liability, or Worker s Compensation Insurance Company (if Claim#: applicable): Claim representative: SECTION III: SIGNATURE (INITIAL) I understand that physical therapy is always voluntary, that there may be OTHER TREATMENT OPTIONS, that there may be RISKS associated with therapy, and that I may at any time, and with any particular treatment, request to discuss those risks with the therapist. With this understanding, I CONSENT TO PHYSICAL THERAPY TREATMENT at Fairbanks Physical Therapy. (INITIAL) I AUTHORIZE INSURANCE BENEFITS TO BE PAID DIRECTLY to Fairbanks Physical Therapy, and have read and agree to the Notice of Financial Policies, provided to me by Fairbanks Physical Therapy. (INITIAL) I HAVE BEEN INFORMED OF THE HEALTHCARE PRIVACY RIGHTS REQUIRED BY LAW, and have read and understand the document Health Information Privacy under HIPAA, provided by Fairbanks Physical Therapy. (INITIAL) I AUTHORIZE RELEASE OF ANY PERSONAL OR HEALTH INFORMATION necessary to process insurance claims or to provide and coordinate treatment. (INITIAL) I HAVE READ, AND AGREE TO, the clinic s ATTENDANCE POLICY as described in the Cancelations and Missed Appointments section of the Notice of Financial Policies, provided to me by Fairbanks Physical Therapy. Signed (patient/legal guardian): Printed Name of Signer: Today s Date: 2
3 HEALTH HISTORY FORM (All answers are optional and confidential. You may leave this form uncompleted if you wish to go over it in person) PATIENT NAME: FAIRBANKS PHYSICAL THERAPY (OFFICE USE ONLY): SECTION I: THE CURRENT PROBLEM What brings you to physical therapy? What is the problem? How long have you had it? Was there a certain event that caused it? Where is the problem? What part(s) of your body? What makes it better? What makes it worse? At the moment, how bad is this problem? Please rate it from zero to 10, zero being no problem at all. What would you rate it at its worst? What would you rate it at its best? SECTION II: SOCIAL HISTORY (each of these questions is optional) With whom do you live, and what is (are) their relationship(s) to you (optional)? What activities (aside from work) do you enjoy doing or need to do for daily life? How are they limited by this problem? Do you consume alcohol? If so, how many drinks per week? Do you use tobacco? If so, how much per week? How many caffeinated drinks (e.g., coffee, soda) do you have daily? SECTION III: OCCUPATIONAL HISTORY What do you (or did you) do for a living? How many hours do you (or did you) work in a typical week? Are you interested in quitting or cutting down on any of these? If you have retired or stopped working, when? How would you describe your work duties? 3
4 HEALTH HISTORY FORM, CONTINUED SECTION IV: MEDICATIONS AND ALLERGIES Please list prescriptions, over-the-counter medications, or nutritional supplements that you take (attach a list): PLEASE LIST ANY KNOWN ALLERGIES (e.g., drugs, seasonal, latex, tape) AND REACTION: SECTION V: PERSONAL AND FAMILY MEDICAL AND SURGICAL HISTORY Have you been diagnosed with or treated for any of these? (Check any that apply) Breathing or lung (respiratory) problems Digestive problems (throat, stomach, bowels) Tuberculosis Urinary problems Problems of the heart or blood vessels (cardiovascular) Kidney (renal) problems Blood pressure or cholesterol problems Liver problems (hepatitis, cirrhosis, etc.) Diabetes Cancer, past or present Bone and joint (musculoskeletal) injuries or disorders Stroke (cerebrovascular accident) Arthritis (osteoarthritis, rheumatoid, psoriatic, etc.) Multiple sclerosis Weakened bones (osteoporosis, osteopenia) Other neurological conditions Depression, anxiety, or other psychological disorders Infections or infectious disease Alcohol or drug addiction, overuse, or abuse Blood disorders (clotting, bleeding, anemia, etc.) Hereditary disorders or diseases Head injury or trauma (including by violence) Glandular (endocrine) disorders (thyroid, prostate, etc.) Other: Please list any health conditions or illnesses of close blood relatives: Height: Current weight: Have you recently had any of these? (Check any that apply) Trouble breathing Vision changes Chest pain Night sweats Heart palpitations Worsening pain at night Bleeding or bruising Fainting or blackouts Leg cramps, redness, or tenderness Dizziness or lightheadedness Recent change in weight, appetite Numbness or tingling Feeling fatigued, weak, or sick Trouble swallowing Nausea or vomiting Unusual skin changes, sensations Headaches Urinary or bowel changes/problems Please list any surgeries you ve had, with approximate dates: Desired weight: Unusual lumps Sexual problems Stiffness in many joints Constant, relentless pain Sadness or depression Fear Hopelessness Confusion/forgetfulness Other: SECTION VII: SAFETY Have you fallen recently during normal daily activity? Do you feel safe at home? Have you felt threatened, controlled by, or afraid of a partner, family member, or caregiver? Do you have any other concerns you wish to discuss confidentially? Do you have a living will or advanced directive? 4
5 HEALTH INFORMATION PRIVACY UNDER HIPAA Your privacy is of utmost importance to us, and Federal law says that you must be informed of your rights and our responsibilities in protecting the confidentiality of every aspect of your treatment at Fairbanks Physical Therapy. The Privacy Rule gives you rights over who can access any of your health information, and how it is shared. The Security Rule gives added protection over electronic health information, such as s we send and receive, and our electronic medical records system. TO PROTECT YOUR INFORMATION, WE ARE REQUIRED TO Put safeguards in place to protect it. Reasonably limit use and disclosures to the minimum necessary to accomplish their intended purpose. Have contracts in place with our contractors and other parties ensuring that we use, disclose, and safeguard your health information properly. Have procedures in place to limit who can view and access your health information. Implement training programs for employees about how to protect your health information. UNDER THE PRIVACY RULE, WE MUST COMPLY WITH YOUR RIGHT TO Ask to see and get a copy of your records Have corrections added to your information Receive a notice that tells you how your information may be used and shared Decide whether to give permission before your information can be used or shared Get a report on when and why your information was shared for certain purposes Ask us questions about your rights. WE ARE ALLOWED TO SHARE YOUR INFORMATION IF IT IS NECESSARY TO Coordinate your care and treatment Pay healthcare providers for your health care and to help run their businesses Inform any family, relatives, friends, or others whom you identify as involved with your healthcare or your health care bills, unless you object Make sure doctors give good care Protect the public's health Report information for legal requirements, such as threats to personal safety UNLESS YOU GIVE PERMISSION, WE CANNOT Give your information to your employer Use or share your information for marketing or advertising purposes Share private notes about your health care IF YOU FEEL WE HAVE VIOLATED YOUR RIGHTS UNDER THIS LAW, YOU CAN File a complaint with your provider or health insurer File a complaint with the U.S. Government FOR MORE INFORMATION, INCLUDING HOW TO FILE A COMPLAINT, VISIT THE DEPARTMENT OF HEALTH AND HUMAN SERVICES WEBSITE AT: OR CALL
6 NOTICE OF FINANCIAL POLICIES COSTS OF PHYSICAL THERAPY Depending on your insurance coverage, the actual cost of therapy to you may vary, but therapy is billed at a standard rate. The cost of the initial evaluation portion of your first visit is $150, and you may receive treatment on the first visit as well at additional cost. Upon your request, I will supply you with a more detailed written fee schedule for all therapy services we provide. If you have no insurance, you may receive a cash payment discount by paying at the time of service (see below). THIRD PARTY (INSURANCE) BILLING, AND YOUR RESPONSIBILITIES If you wish, we will bill your insurance and have their payments sent directly to us, and you will be responsible for any deductible or co-payment. After insurance pays its portion, you re responsible for the remaining balance, with some exceptions. Many insurance companies, because of our contractual agreements with them, limit the amount that can be billed for therapy (the allowed amount ), and place a limit on what patients must pay. We encourage you to call your insurance company with some questions about your policy (see the document Calling Your Insurance Company), take notes, and bring the form to your first therapy visit. If your insurance changes, please let us know as soon as possible, to avoid your insurance company denying coverage. NON-INSURANCE-FEE-FOR-SERVICE (THE CASH-PAY DISCOUNT ) If you have no insurance, or wish not to have your insurance billed, you may opt for a fee-forservice or cash-pay discount. If all charges are paid at the time of service, we ll discount our standard fees by one-third (about 33%). In certain instances, you may qualify for further reduction for reasons of financial hardship. CANCELATIONS AND MISSED APPOINTMENTS It is important to show up for your scheduled appointments, and within a reasonable amount of time. If you are unable to make it to the appointment, it is necessary to let us know at least 24 hours in advance. It is the policy of this clinic to discontinue your therapy after you have missed two appointments without calling, after three missed appointments without 24 hours notice, or after a consistent pattern of late arrivals without previous arrangements. There is a $50 charge (not covered by insurance) for appointments missed with insufficient or no advance notice. Case-by-case exceptions may be made depending on circumstances (e.g., unexpected illness, emergencies, etc.). PAYMENT AND BILLING We do not collect payment at the time of service, but you may wish to make payments per visit by calling Fairbanks Billing Services, LLC (FBS) at (907) FBS will manage all billing for your therapy services, including submission of claims to insurance companies and billing patients or other responsibilities for remaining balances. Please direct all billing questions to FBS. PLEASE FEEL FREE AT ANY TIME TO ASK FOR CLARIFICATION OF THESE POLICIES, OR TO DISCUSS ANY FINANCIAL CONCERNS YOU MAY HAVE. 6
7 CALLING YOUR INSURANCE COMPANY INSTRUCTIONS: It is important and necessary be informed about your health benefits under your insurance policy, so that you may make informed decisions about purchasing health care services. If you will be using any private, non-governmentsponsored health insurance to pay for therapy (including secondary insurers), we ask that you take a few minutes and call the toll-free number on your insurance card. WHAT TO SAY: I d like to ask some questions about my outpatient physical therapy benefits. Then ask them the following questions, write down the answers, and bring the completed form with you to your first therapy visit. 1. Do I need to have a physician s prescription for therapy? 2. What is my co-pay for a therapy visit? 3. How many visits are allowed? 4. How many visits have I used to date? 5. What is my annual deductible for outpatient physical therapy? 6. How much of my deductible have I met? 7. When does my benefit year start (at the beginning of the calendar year or not)? 8. Do I need pre-authorization? If so, what number do I call? (If this is required, call the number before your first visit) 9. What rules apply to my authorization? For example, do I have to get re-authorized after a certain number of visits, or every year on a certain date? 10. Do I have out-of-network benefits for outpatient physical therapy services? If so, please summarize them. 7
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BIRTHDATE - - AGE SEX EMERGENCY CONTACT PHONE( )
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LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP OCCUPATION EMPLOYER/SCHOOL WORK PH
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HI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy)
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DEMOGRAPHIC FORM Today s date: Dr. Doug S. Clouse Dr. Benjamin MacQueen Dr. D. Gregory Stewart Name (Last, First, MI): Home phone no.: Cell phone no.: PATIENT INFORMATION Marital status (circle one) Single
Copayment Is Due At Time Of Visit. Self-pay (payment due at time of service)
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Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone
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Hello, Please note: The following information will be needed at your appointment:
Hello, You are receiving this mailing because you or a family member have an upcoming appointment at the Albany Medical Center s Neurology Group as noted above. Our goal is to provide you with the best
DATE OF BIRTH SOCIAL SECURITY (Last 4 digits): SEX: Male Female
PATIENT DATA SHEET PATIENT INFORMATION Please complete this form in its entirety prior to your first visit. Also, please bring your insurance information and/or cards to our office at your first visit.
PATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )
PATIENT INFORMATION PATIENT S LEGAL NAME DATE OF BIRTH AGE DATE / / / / HEIGHT AND WEIGHT SEX REASON FOR VISIT: MARITAL STATUS FT IN LBS MALE FEMALE S M D W ADDRESS CITY STATE ZIP CODE THE BEST NUMBER
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Name Home phone Work phone. Address. Email address. Date of birth Gender (circle): M F Marital status No. of children. Name of partner Referred by
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