Valk THE SPORTS REHABILITATION CENTER

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1 Valk Welcome to The Sports Rehabilitation Center. Our services include physical therapy by a licensed physical therapist. We appreciate your selection of our facility to serve your rehabilitation needs. You can expect our consistent commitment to your care. Provided for you is a list of our Policies & Procedures. Please review, sign your acknowledgement where indicated and return it to our front office. OFFICE HOURS & APPOINTMENTS We are open Monday through Friday, with the first appointment at 7 a.m. and the last appointment at 6 p.m. Your first appointment is an evaluation, which is required by state law. This evaluation allows the therapist to determine the treatment plan from a therapeutic standpoint. Your subsequent appointments must be scheduled with your therapist. We will try to accommodate your schedule, however, it is important TO SCHEDULE YOUR APPOINTMENTS EACH WEEK FOR THE FOLLOWING TWO WEEKS TO ENSURE AVAILABILITY. Please attend your appointments on time. If you r are late, you not only affect your care, but the therapy of others. CANCELLATION POLICY We schedule patients to provide quality care, not just symptomatic relief Thus, patients are expected to attend every scheduled session on time. If an unforeseen circumstance arises and your appointment must be rescheduled, please contact us at least 24 hours in advance. If you fail to show up for an appointment or fail to give 24 hours cancellation notice, a fee of $50 will be added to your account to be paid prior to your next visit. With two consecutive cancellations, reschedules or no-shows we remove you from the schedule and will not be able to treat you until you return to your physician. SIGN IN PROCEDURE When you arrive, please sign in so that your therapist can be notified of your arrival. If you require a locker for changing, please let us know when you sign in. After changing, please return to the waiting area and have a seat. The therapist will come and get you when they are ready for you to begin therapy. In exchange for a locker key, we require that you leave your keys with us so we can properly receive our locker key when you are done with therapy. CHANGE OF INFORMATION It is important that we have current patient information in our records. Please advise the front office staff of any changes of address, phone number, insurance information, etc. that may have occurred. MIDTOWN DUNWOODY BROOKHAVEN

2 PERSONAL Last Name: NEW PATIENT INFORMATION SHEET First Name: MI: Address: City: State: Zip: Address: Home #: Cell #: Date of Birth: Age: Gender: SSN: Referring Physician: Married ( ) Single ( ) Divorced ( ) Partnered ( ) (check one) EMPLOYMENT Employer: Office Phone #: Job Title: Years of employment: Employer Address: City: State: Zip: INSURANCE INFORMATION Insurance Company Name: Phone #: Address: City: State: Zip: ID#: Group#: W/C Claim #: (if applicable) Primary Insured: ( ) Self ( ) Spouse ( ) Parent Name of Insured: ) Employer ( ) Other Insured Date of Birth: Address: City: State: Zip: (if different from above) Home#: Work#: SSN of Insured: Insured Employer: Insured Job Title: Employer Address: City: State: Zip: Authorization to Release Medical Information/Assignment of Benefits I hereby assign all medical benefits to which I am entitled to The Sports Rehabilitation Center in the event that they file insurance on my behalf and I authorize said assigns to release all information necessary to secure the payment of said benefits. I am aware that I am financially responsible for all charges whether or not paid by said insurance. A copy of this assessment shall be considered as effective and valid as the original. MIDTOWN Signature of Patient or Responsible Party DUNWOODY BROOKHAVEN Date

3 FINANCIAL/INSURANCE INFORMATION We will file all claims with your primary insurance carrier. However, we will need your assistance in any problems that may arise, as you are ultimately responsible for your bill. You will need to pay the full amount of your bill until your deductible is met. Then the percentage of charges not covered by your primary insurance carrier will be collected on a weekly basis. Any remaining balance after your primary insurance coverage has been paid is due from you upon receipt of our bill. When verifying your insurance coverage, your insurance company may tell us your percentage of covered physical therapy charges (example: 80%). However, this is often misleading. Each insurance company has their own "reasonable & customary" fee schedule that they consider being acceptable charges. Insurance companies also may have "per visit" limits or may "not cover" specific charges. When we verify insurance, we strive to obtain as much information as possible. However, insurance companies often will only disclose a certain amount of information to us "the providers". We encourage you to verify the specifics of your policy with your insurance company in order to clarify exactly what is covered, not covered, etc. Any overpayments will be refunded after all charges have been processed by your primary insurance. Please be aware that secondary insurance will be your responsibility to file and collect. CHARGES We are unable to predict exact charges, as it depends on the therapeutic care you receive by your therapist. Your first office visit to THE SPORTS AT GEORGIA TECH is payable by you at the time of your appointment. We will gladly provide an explanation of charges upon request. MEDICAL RECORDS Your medical records are held in the strictest confidence. If you wish information about your condition to be provided to a third party, they should provide us with a written authorization signed by you. Thank you for allowing us the opportunity to serve you. If you have any questions about the above information or any uncertainty regarding your insurance coverage, please ask for assistance. I have read, fully understand, and will abide by THE SPORTS REHABILITATION CENTER policies. Signature of Patient or Responsible Party Date MIDTOWN DUNWOODY BROOKHAVEN 5342 TILLY MILL ROAD

4 Vat "ff Cancellation and No-Show Policy Dear Patient, The Sports Rehab Center is committed to offering you the best possible treatment administered by our highly skilled staff. We go to great lengths to ensure that your treatment experience is successful in achieving a rapid recovery. We have attempted to be flexible with our hours of operation and try to accommodate our patients' schedules without making them wait to get in for an appointment. However, any no-shows or cancellations made within 24 hours means that we have an unstable time slot. Therefore, cancellations and no-shows made within 24 hours will be charged $50.00 We will continue to provide the high standard of care and ask that you commit to your scheduled appointment. Your insurance company will not cover this fee. Please note that by not signing this form I am not exempt from this policy. It just acknowledges disagreement. By signing below I acknowledges that I have read and agree to this policy. Patient Signature Date MIDTOWN DUNWOODY BROOKHAVEN FAx PHONE

5 Wit NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The Health Insurance Portability & accountability Act of 1996 (HIPAA) is a federal program that require that all medical records and other individually identifiable health information used or disclosed by us in any form whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the patient, penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations. Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical therapy examination. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment. Health care operations includes the business aspect of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer and/or Office Manager. MIDTOWN DUNWOODY BROOKHAVEN

6 Vaik The right to request restrictions on certain issues and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. The right to inspect and copy your protected health information. The right to receive an accounting disclosure of protected health information. The right to receive a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to your protected health information. This notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make new provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health & Human Services, Civil Rights, about violations of the provisions if this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint. For more information speak to our compliance officer or office manager: The Sports Rehabilitation Center MIDTOWN DUNWOODY BROOKHAVEN th STREET NW 5342 TILLY MILL ROAD 5290 ROSWELL ROAD, SUITE W ATLANTA, GA DUNWOODY, GA ATLANTA, GA ATLANTA, GA PHONE: PHONE: PHONE: PHONE: FAX: FAX: FAX: FAX: MIDTOWN For more information about HIPAA or to file a complaint: The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Avenue SW Washington, D.C Toll Free: ru STREET PHONE FAX DUNWOODY BROOKHAVEN PHONE PHONE FAX

7 Valk Brian J. Tovin, PT, DPT, MMSc, SCS, ATC, FAAOMPT Jason Reiss, PT, DPT, OCS Michelle Miller, PT, MPT Christine Olson, PT, MSPT Katharine Wells, PT, DPT Elizabeth Swift, PT, OPT Christynne Papincak, DPT Tiffany Davenport, DPT Rhett Roberson, Fr, DPT, OCS Keely Towson, MPT, cscs Anisha Drake, PT, DPT Andrea O'Neal, PT, MPT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OR PRIVACY PRACTICES *YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGMENT* Practices. received a copy of this office's Notice of Privacy Please Print Name Signature Date DATE: INITIALS: We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign [Communications barriers prohibited obtaining the acknowledgement [An emergency situation prevented us from obtaining acknowledgement [Other MIDTOWN DUNWOODY BROOKHAVEN

8 Vat REHABILITATION Cl.ENTER 1. Have you ever a been to a physical therapist? a. yes b. no 2. Have you ever been a patient here before? a. yes b. no 3. How did you hear about us? a. Doctor's referral b. Friend/relative c. Your insurance network d. Website/Sign out front e. Other 4. Are you here because of: a. non-surgical injury b. post-operative rehabilitation c. wellness visit d. sports performance improvement e. other 5. If you are an athlete, please let us know which sport you play: a. running b. golf c. swimming d. tennis e. baseball f. football g. other 6. Is your injury or visit sports related? a. yes b. no Physical therapist to fill out: PT Diagnosis: We appreciate you taking time to fill this out! MIDTOWN DUNWOODY BROOKHAVEN FAx

9 ram, I. REHABILITATION C ENTER Atlanta's Leader in Orthopedic and Sports Physical Therapy Date: Name: MEDICAL SCREENING FORM Referring MD: Diagnosis: Please Circle Yes or No Have you or anyone in your immediate family Ever been diagnosed with? You Family Cancer Diabetes. High Blood Pressure Heart Disease Angina/Chest Pain Stroke Osteoporosis. Rheumatoid Arthritis... In the past three months have you experienced any of the following symptoms? Change in general health Nausea/Vomiting Fever/Chills Unexplained weight loss Numbness or tingling Change in appetite Difficulty swallowing. Changes in bowel or Bladder functions Shortness of breath Dizziness Upper Respiratory Infection Urinary Tract Infection *Following information is mandatory: List any current medications. Name Dosage/Freq Route Please Circle Yes or No Do you have a history of? Asthma/Allergies Headaches Bronchitis Kidney Disease Rheumatic Fever Ulcers Sexually Transmitted Diseases Seizures Are you currently? Pregnant Depressed Under stress Are your symptoms: (circle one) Staying consistent Getting worse Improving How are you sleeping at night? Only Medicated Moderate Difficulty Fine Do you have problems with: (check all that apply)? Communication Speech Vision Hearing Do you or have you in the past smoked tobacco? No Yes Please list any other Past Medical History. WEIGHT: HEIGHT: FT. IN. MIDTOWN DUNWOODY BROOKHAVEN

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