CAMARILLO AQUATICS AND REHABILITATION SERVICES

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1 CAMARILLO AQUATICS AND REHABILITATION SERVICES Last Name First M.I. Address Apt.# City State Zip Code Phone # SS# Date of Birth Sex M F Driver s License # Marital Status: S M D W Spouse s Name How did you hear about us? Newspaper Radio Yellow Pages Internet Other: Referring Doctor Doctor s Phone # Diagnosis Date of Injury Is this a work related injury? Yes No Is this an auto accident related injury? Yes No Is there an attorney involved? Yes No PATIENT WORK INFORMATION: Employer s Name Employer s Address City State Zip Code Work Phone # Ext. Employee ID# Occupation MEDICARE INFORMATION: Medicare # (if applicable) PRIVATE INSURANCE INFORMATION: Insurance Company Name Policy # Group # Certificate # Phone # Address Apt.# City State Zip Code Is this your coverage? Yes No If no, whose name is on policy? Your relationship to the insured? IN CASE OF EMERGENCY PLEASE CALL: (Name, Phone #, relationship) 1 of 7

2 SECONDARY INSURANCE INFORMATION: Name of Insured Relationship Insurance Policy # Group # Insurance Company Name Phone # Ins. Co. Address City State Zip Code AUTO INSURANCE INFORMATION: Name of Insured Auto Insurance Company Name Address City State Zip Code Policy # Claim # Adjustor s Name Phone # WORKER S COMPENSATION INFORMATION: W/C Insurance Co. Phone # Address City State Zip Date of Injury Body Part Adjustor s Name Claim # Auth. visits Freq. Duration Employer s Name (at the time of injury) Phone# ATTORNEY INFORMATION: Name Phone # Address City State Zip Code AUTHORIZATION TO PAY CAMARILLO AQUATICS & REHABILITATION SERVICES Assignment of Benefits I hereby authorize my insurance benefits to be paid directly to CAMARILLO AQUATICS & REHABILITATION SERVICES and I understand that I am financially responsible for non-covered services and any amount not paid by my insurance. I understand that CAMARILLO AQUATICS & REHABILITATION SERVICES is not a provider for MEDI-CAL services. I also authorize CAMARILLO AQUATICS & REHABILITATION SERVICES to release any information to process this claim. SIGNED: DATE 2 of 7

3 MEDICAL HISTORY QUESTIONNARIE Please list all medications you are currently taking or have taken in the past month. Do you have any allergies? Yes No Please list types of allergies (i.e. food, medication etc.) Have you ever had any serious illnesses/accidents/hospitalizations or surgeries? Yes No Please list with approximate dates Family History: (Circle any that apply) Father: Age now or at death Cancer, Tuberculosis, Diabetes, Heart Disease, Stroke, Other Mother: Age now or at death Cancer, Tuberculosis, Diabetes, Heart Disease, Stroke, Other Personal History: Head and Neck Severe Headaches Yes No Double Vision Yes No Swelling in Neck Yes No Dizzy Spells Yes No Discharge/Ear Yes No Fainting Yes No Failing Vision Yes No Prolonged Hoarseness Yes No Stroke Yes No Heart and Lungs Chest Pain Yes No High Blood Pressure Yes No Tuberculosis Yes No Heart Attack Yes No Difficulty Breathing Yes No Spit up Blood Yes No Skipping Heart Beats Yes No Pneumonia Yes No Ankles Swell Yes No Chronic Cough Yes No Heart Defects/Murmur Yes No Stomach and Intestines Persistent Nausea Yes No Skin Turns Yellow Yes No Blood from Rectum Yes No Heartburn Regularly Yes No Any Chronic Diarrhea Yes No Habitual Constipation Yes No Loss of Appetite Yes No Black Stool Yes No Hemorrhoids Yes No Diabetes Yes No Ulcers Yes No Urinary Tract (Women Only) Excess Urination Yes No Leakage of Urine Yes No Painful Menstruation Yes No Difficult Urination Yes No Passed Any Stones Yes No Excess Menstruation Yes No Blood in Urine Yes No Retention of Urine Yes No Bleed between Periods Yes No Excess Night Urination Yes No Missed Periods Yes No Pregnancies (How Many) Muscles-Joints-Nerves Tingling Sensations Yes No Nervous Breakdown Yes No Speech Disturbances Yes No Numbness Yes No Memory Loss Yes No Seizures Yes No Disturbance in Walking Yes No Personality Changes Yes No Emotional Problems Yes No Muscle Jerking Yes No Paralysis Yes No Varicose Veins Yes No Do you smoke or have you ever been a smoker? Yes No If yes, how long? Do you drink alcoholic beverages? Yes No How much? How Long? Have you ever been addicted or habituated to drugs? Yes No If yes, please explain Are you on a special diet or have any dietary restrictions? Yes No If yes, please explain Are you currently under the care of another physician(s) for any other conditions? Yes No Signature: Print Name: Date: 3 of 7

4 CAMARILLO AQUATICS & REHABILITATION SERVICES CONSENT FORM Physical Therapy is a patient care service provided in response to a wide range of medical care needs of outpatients of all ages regardless of gender, color, race, creed, national origin, or disability. The purpose of physical therapy is to treat disease, injury, and disability by evaluation, examination, testing and use of rehabilitative procedures, mobilization, massage, exercises and physical agents to aid the patient in achieving their maximum potential within their capabilities; and to accelerate convalescence and reduce the length of the functional recovery. All procedures will be thoroughly explained to you before you are asked to perform them. You are expected to cooperate fully with the evaluation and treatment program. Because of the nature of services provided you might be asked to disrobe. If this is necessary, your privacy, modesty and dignity will be considered at all times by the staff. Should you feel uncomfortable or embarrassed, you may refuse the procedure, stop the procedure and/or request another therapist. There are certain inherent risks with physical therapy treatments because you will be asked to exert effort and perform activities with increasing degrees of difficulty which could cause an increase in your current level of pain or discomfort or an aggravation to your existing injury. You will be able to stop treatment if you feel any discomfort or pain. Your physical therapist will take every precaution to ensure that you are protected from any potentially hazardous situation. You will never be forced to perform any procedure, which you do not wish to perform. Because of the nature of the procedures performed within the clinical setting, your communication with family and friends may be restricted. Camarillo Aquatics & Rehabilitation Services reserves the right to restrict visitors and outside communication at any time during your treatment sessions to ensure you receive the maximum therapeutic value from treatment. Based on the above information, I agree to cooperate fully, to participate in all physical therapy procedures, and to comply with the plan of care as it is established. I have read and received a copy of the consent form and authorize release of medical information to appropriate third parties. Date Patient s Signature 4 of 7

5 CAMARILLO AQUATICS & REHABILITATION SERVICES Cancellation and No-Show Policy It is important for you to attend your scheduled appointments to achieve the goals your physician and your therapist have established for you. If you must cancel a scheduled appointment, please call Camarillo Aquatics & Rehabilitation Services as soon as possible. For your convenience, our telephones are on an automatic answering machine during off hours. Camarillo Aquatics & Rehabilitation Service s Phone Number (805) The following is our policy for cancellations and no-shows (missed appointments without calling to cancel). If you cancel with notice of less than 24 hours or no-show, a $40.00 fee will be charged. For consideration of reversal of this charge you must submit your request in writing to the Director (Owner) of Camarillo Aquatics & Rehabilitation Services with an acceptable excuse. The therapist and receptionist do not have the authority to make these decisions. If you cancel twice consecutively with notice of less than 24 hours, a $40.00 fee will be charged for each missed appointment and all remaining appointments will be deleted. Future appointments may only be made on the day you can come, provided we have an available appointment. If you no-show twice, all remaining appointments will be deleted, a $40.00 fee will be charged for each missed appointment, and your physician will be notified. It will be necessary for you to submit a request in writing to the Director of Camarillo Aquatics & Rehabilitation Services for approval to schedule future appointments. I have read the Cancellation and No-Show Policy of Camarillo Aquatics & Rehabilitation Services and I understand its contents. Patient s Signature Date 5 of 7

6 Camarillo Aquatics & Rehabilitation Services NOTICE OF PRIVACY PRACTICES We protect the privacy of our patient s health information as required by law, practice standards, and our internal policies and procedures. This privacy statement explains your rights, our legal duties, and our privacy practices. Your Health Information THIS NOTICE DESCRIBES YOU MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY. We collect, use, and disclose information provided by and about you for medically necessary treatment, health care payment and operations or when we are otherwise permitted or required by law to do so. For Treatment: We may use and disclose information about you in providing, coordinating, or managing your treatment and wellness activities. We may provide referring physicians, other providers, and other alternative practitioners information about your treatment when they are appropriately involved with the treatment process. For Payment: We may use and disclose information about you in managing your medical file, to secure treatment authorization, to confirm insurance coverage, for medical billing and receiving payments for medical care through your health plan or other similar entities. We may also provide information to a doctor s office, hospital, or other health care providers or health plans to confirm your eligibility for benefits, medical diagnosis, treatment, and other medically necessary information in order to provide appropriate services and receive payment. For Health Care Operations: We may use and disclose medical information about your for our operations. For example, we may use information about you to review the quality of care and services you receive; to provide you medical file management or coordination of medical services such as between treating therapists or between doctor and therapist. As Permitted or Required by Law: Information by you may be used or disclosed to regulatory agencies, such as during audits, licensure, or other proceedings; for administrative or judicial proceedings; to public health authorities; or to law enforcement officials, such as to comply with a court order or subpoena. Authorization: Other used and disclosures of protected health information will be made only with your written permission, unless otherwise permitted or required by law. You may revoke this authorization, at any time, in writing. We will then stop using your information for that purpose. However, if we have already used your information based on your authorization, you cannot take back your agreement for those past situations. Your Rights Under regulations that will be in effect on April 14, 2003, you will have additional rights over your health information. Under the new rules, you will have the right to: Send us a written request to see or get a copy of information that we have about you, or amend your personal information that you believe if incomplete or inaccurate. If we did not create the information, we will refer you to the source, such as your physician or hospital. Request additional restrictions on uses and disclosures of your health information. We are not required to agree to these requests. Request that we communicate with you about medical matters using reasonable alternative means or at an alternative address if communications to your home address could endanger you. Receive an accounting of our disclosures of your medical information, except when those disclosures are made for treatment, payment, or health care operations, or the law otherwise restricts the accounting. We are not required to give you a list of disclosures made before April 14, Complaints If you believe your privacy rights have been violated, you have the right to file a complaint with us, or with the federal government. You will not be penalized for filing a complaint. 6 of 7

7 Copies and Changes You have the right to receive an additional copy of this notice at any time. We reserve the right to revise this notice. A revised notice will be effective for information we already have about you as well as any information we may receive in the future. We are required by law to comply with whatever privacy notice is currently in effect. We will communicate any changes to our notice through direct mail. Contact Information If you want to exercise your rights under this notice or if you wish to communicate to us about privacy issues or to file a complaint with us, please contact our privacy officer at: Declaration of Privacy of Health Information All medical records and other individually identifiable health information used or disclosed by a covered entity in any form, whether electronically, on paper, or orally, are covered by the US Department of Health and Human Services (HHS), and are covered by HIPAA (Health Insurance Portability and Accountability Act of 1996). Further, I authorize that the results of any assessments or records given to me may be used in completing evaluations, assessments, treatment plans, progress reports, summary reports, discharge summary reports and medical billing and reimbursement. I understand that such reports will only report aggregated data, and will only be used for health care purposes such as third party payment and physician or other authorized health care provider treatment or progress reports. I understand I can restrict the uses and disclosures of my medical information. I understand that I have the right to file a formal complaint with a covered provider or health plan or HHS about violations regarding my health and medical records or information. This release is and shall be binding upon my heirs, assigns, executors, and administrators. Restrictions requested by client: Signature of Patient: Date: 7 of 7

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