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1 Welcome to our practice. Please complete all sections below. The signature of the patient, the custodial parent, or the legally responsible party is required. Please print all information. PATIENT INFORMATION: Name: DOB: / / DATE: Male Female Mailing Address: City: State: Zip: Street Address (if different from above): Phone Numbers: Home: Work: Cell: Address: Primary Care Physician: Phone: PHARMACY INFORMATION: Name: Location: Phone: EMERGENCY CONTACT: Name: Relationship to Patient: Address: City State: Zip: Phone Numbers: Home: Work: Cell: IF PATIENT IS A CHILD: Father s Name: DOB: Mother s Name: DOB: COMPLETE THIS SECTION ONLY IF WORKERS COMPENSATION Date of Injury / / Have you been seen elsewhere for this injury? YES NO If so, where? Employer Name Phone Address City St Zip Supervisor / Contact Name Employer s Insurance Company Claim # Phone Address City St Zip ETHNICITY: DECLINE African Asian Cuban Hispanic or Latino Irish Italian Jewish Korean Native American Non Hispanic or Latino Polish Russian RACE: DECLINE Multiracial American Indian Asian Indian Black Chinese Filipino Guarmanian Hawaiian Hispanic Japanese Korean Russian Samoan Vietnamese White PREFERRED LANGUAGE: English German Spanish

2 PRIVACY PRACTICES (HIPAA) By signing below I acknowledge that I was provided with the Notice of Privacy Practices of South County Orthopedics. Please list any persons to whom your protected health information can be disclosed (e.g., spouse, parent, etc.). This list should include your emergency contact person. Signature of patient/legally responsible party: Date: Printed name of legally responsible party: PERMISSION TO LEAVE MESSAGES: By Signing Below, I authorize South County Orthopedics to leave non clinical messages in reference to any items that assist in carrying out my healthcare. What is the best number to reach you: ( ) Can we leave messages at this number? Yes No Would you like to receive TEXT reminders? Yes No Cell: ( ) Would you like to receive reminders: Yes No Signature: Date: RX HISTORY CONSENT: By signing below, I agree to allow South County Orthopedics to review any prescription history available to my electronic health record. Signature: Date: Disclosure Of Protected Health Information Of A Minor (only applicable for minor patient s age 11 through 18th birthday) I understand that medical records containing the following information about the care listed below: o HIV testing and treatment o Testing and treatment for reportable sexually transmitted diseases; o Family Planning and abortion services; and o Alcohol and drug treatment services. by law, cannot be disclosed by South County Orthopedics to the parent/guardian of a minor patient unless permission is granted by the minor. On some occasions, SCO may call the minor about the release of his/her information. Minor cell phone number: I agree that the above stated information is correct and accurate to the best of my knowledge. Signature: Date:

3 ORTHOPEDIC MEDICATION RECONCILIATION SHEET NAME DOB Please list any medications that you currently use, including over-the-counter medications, vitamins, herbs, and prescribed drugs. NONE MEDICATION DOSE/STRENGTH FREQUENCY SIGNATURE DATE

4 SOUTH COUNTY ORTHOPEDICS & PHYSICAL THERAPY, INC. FINANCIAL AGREEMENT Patient Name / / Date of Birth We emphasize that our relationship is with you, not your insurance carrier or a third party. This is an agreement between South County Orthopedics and the Patient/Guarantor. Insurance claims are filed as a courtesy to our patients but any charges are ultimately your responsibility. By executing this agreement, you are acknowledging the financial obligation for ALL services rendered. Our office policy is to obtain full payment at the time of service. If full payment is not received once treatment has been provided, any balance on your statement is due upon receipt. We reserve the right to refuse additional services on delinquent accounts. If you have medical insurance: Your financial responsibility depends on the coverage provided by your insurance contract. You need to know and understand your policy benefits. The contract is between the insurance company, you and your employer (if applicable). We are not party to that contract. Please confirm the insurance information we have on file is correct and inform us of any changes to your coverage in order to insure accurate processing of your claims. Physicians, Physician Assistants, and/or our facility may not be contracted as providers with your insurance carrier. It is your responsibility to verify insurance coverage and eligibility with your insurance carrier prior to service. Deductibles, co-pays and any out of pocket expenses will be paid at the time of service by cash, check or credit card. In the event services were rendered and copayment can not be collected at the time of service, a $20.00 billing service fee will be applied. Any balance on your statement is due upon receipt. If you have no medical insurance: A deposit for the initial office visit is $ Payment for future office visits are expected at the time of service, regardless of your initial deposit balance. Any excess balance will be applied to your account or refunded once full treatment has been completed. You may pay by cash, check or credit card. If unable to pay in full at the time of your service, a payment plan can be arranged with our billing department. If surgery is required, 50% of the cost of the procedure must be paid prior to your surgery date. This is only relating to the professional services of our doctors and is independent of any hospital or other expenses. Medicare Patients: You are responsible for the 20% co-payment on the date of service. If you have a Medicare supplement, we will file a claim with them provided they will make payment directly to our office. Minor Patients: For all services rendered to minor patients, we will look to the adult accompanying the patient and the parent/guardian with custody for payment and signature of this policy. Automobile Accident Patients: We do not hold for litigation. Payment is to be made at the time of service. It is the patient s responsibility to submit claims to their attorney. Durable Medical Equipment (DME): If you receive any DME not covered by your insurance carrier, you are responsible for payment. All DME is non-refundable. DME includes, but are not limited to: braces, slings, & walking boots. Delinquent Accounts: We refer delinquent accounts to an outside collection agency for recovery when full payment has not been received after a prescribed number of statements and verbal contacts with you or the responsible party. Returned Checks: In the event that you issue a check that is not honored or paid by your financial institution, you will be charged a $25.00 returned check fee. By signing below, I acknowledge, understand, and agree to the above information. / / Patient / Guarantor Signature Date Relationship to Patient FINANCIAL AGREEMENT_OFFICE POLICIES.doc 9/9/2013

5 Informed Consent Please take a few minutes to read the following information. This information will give you a better understanding of the role of physical therapy in your rehabilitation and some of our clinic policies regarding your appointments. Physical therapy is used to: 1. Alleviate pain 2. Prevent or reduce impairment, functional limitation, disability or changes in physical function and health status. 3. Restore, maintain, and promote overall fitness, health and optimal quality of life. Physical therapists have completed a Bachelor, Masters or Doctorate program of study and passed a state licensure examination. We are not physicians and do not order radiological or laboratory tests, or prescribe medication. Physical therapists are trained to evaluate, test and measure the function of the musculoskeletal, neurological, and cardiovascular systems. Tests are administered to identify potential and existing problems. A variety of hands-on techniques, therapeutic exercises, and/or machines are utilized to correct posture, control pain, and restore movement and function. Physical therapy includes services rendered by support staff under the supervision and direction of the physical therapist. South County Orthopedics Physical Therapy Department is completely owned by our physician partners. If you choose to have treatment elsewhere, we will gladly provide you with all necessary referral information. LATE POLICY: Promptness is important to us. We make all attempts to start your visit at your scheduled appointment time to ensure that you receive the best possible care. If you arrive 15 minutes or more past your scheduled time, your appointment may have to be rescheduled. NO-SHOW POLICY: If you are unable to make your appointment we ask that you call the office in advance to cancel. If you do not call to cancel, all future appointments may be forfeited and you will be charged a $25 no-show fee. Please feel free to ask questions concerning your physical therapy. We look forward to assisting you in your rehabilitation. I have read this consent to my participation in physical therapy at South County Orthopedics & Physical Therapy, Inc. Patient Signature Date Patient (Print Name)

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