Optimum Performance Physical Therapy, LLC
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1 Optimum Performance Physical Therapy, LLC Patient Information: Name: DOB: SS# Address: Phone: (H) (W) (C) Sex: Male Female Marital Status: M S D W Employer Name/ Address: Referring Physician: (P) Primary Care Physician: (P) Body Part: Injury: Surgery: Insurance Information: Primary Insurance: Policy # Group # Policy Holder: DOB: SS# Phone # Secondary Insurance: Policy # Group # Policy Holder: DOB: SS# Phone # WKCP (Worker s Compensation) Carrier s Name: DOI: Claim #: Billing Address: Adjuster: (P) Referring Physician: How did injury occur: Surgery: Type of Surgery: MVA (Motor Vehicle Accident) Name of Auto Insurance: DOA: Claim #: Billing Address: Were they seen anywhere after the accident: I have reviewed the above information, other than any changes indicated above; I found the information to be correct. I have been informed of the coverage verified and understand that this is only a verbal verification of benefits, not guarantee of payment by my insurance company. This is not a guarantee of payment. We encourage you to independently verify you own insurance. Patient Signature: (seal) Date:
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4 OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC Payment Policy and Procedures Please read carefully before you sign. Your signature acknowledges understanding of items set forth herein. If you have questions regarding any sections, please ask our staff for assistance. Release of Information I give permission to OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC, to release information, verbal and written, contained in my medical record, and other related information, to my insurance company, rehab nurse, case manager, attorney, employer and/or related healthcare provider, assignees and/or beneficiaries and all other related persons as it relates to my treatment. I authorize OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC to obtain medical records and/or professional information from my physician and other medical professionals as it relates to my treatment. Consent to Medical and Therapeutic Services I consent to the procedures, which may be performed during the duration of care at Optimum Performance Physical Therapy, LLC. I understand that if I fail to carry out the follow-up medical care, I do so at my own risk. I also understand that the rehabilitation process, by its very nature, involves certain inherent and unavoidable risks, including falls, and other similar injuries, and the only alternative to entirely avoid these risks would be to forego rehabilitation altogether. I understand that I have been referred for rehabilitative treatment and care to Optimum Performance Physical Therapy, LLC. Optimum Performance Physical Therapy, LLC has described my individual treatment plan. I understand that I have the right to have any questions answered prior to receiving any treatment, including any risks or alternative treatment plan that has been prescribed by my physician and or recommended by my therapist. Financial Agreement/ Guarantee of Payment and Assignment of Benefits I request that payment of authorized insurance company(s), attorney, or legal representative, be made on my behalf to OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC. I authorize, OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC, if it chooses, to pursue on my behalf any appeals of the denial of my insurance benefits, and to release my medical records as required to determine benefits payable. OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC, its agents and employees are hereby released from any and all liability of any nature that may arise from the release of information. I guarantee the payment of the full and entire allowed amount of all bills for services rendered for the patient. Any self-pay amounts not paid within forty-five (45) days of any notice of non-payment shall be subject to progressive collection activities up to and including referral to an independent collection agency. I also understand that all insurance coverage quoted to me and /or responsible parties are estimated and final determination of benefits and coverage lies with my insurance company. I certify that I have disclosed any and all health coverage information and I agree to provide OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC, with any changes in my insurance coverage in a timely manner. I understand that as a courtesy and based on the information I provide, OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC, will attempt to verify my insurance benefits. I understand that verification is never a guarantee of payment. I am responsible for payment of all co-pays and coinsurance estimates at the time of service and that these estimates may be higher than those for my primary care physician. Once my insurance company has processed claims, if the amount collected at the time of service was not enough to cover my portion, I may be billed in addition to cover my portion. Likewise, if the estimate I paid was more than my portion, I may be entitled to a refund. After 90 days of billing any secondary payer, unpaid coinsurance may become my responsibility. Printed Name of Patient or Guardian (seal) Signature of Patient or Guardian Date
5 OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC Managed Care Plan Obligations I understand that my insurance carrier may require me to have a current and complete written referral from my primary care physician. I understand that OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC, recommends I check with my carrier directly. If a referral is required and is not presented prior to my treatment being rendered, my insurance may not cover all or a portion of the medical expenses incurred. In this instance, I am responsible for all uncovered charges. It is my responsibility to assist OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC in obtaining additional referrals when necessary and appropriate. Should I require additional or more specific information regarding my insurance coverage, I will contact my carrier directly. Cancellation/No Show Policy It is our desire at OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC to provide every patient with the highest quality of care and services in a timely manner. Therefore, we provide a reserved time slot for each patient so there is minimal waiting and each patient receives individual care. In order to continue with this high quality service, we ask that you call at least 24 hours in advance if you are unable to keep your scheduled appointment. Missed appointments will result in a $40.00 no show charge. Furthermore, additional scheduled visits may be automatically cancelled. We understand that personal schedules can be hectic, but in order to accommodate the needs of all our patients, we must maintain some level of accountability. Missed appointments on your part do not allow for continuity of care and affects your ability to reach the goals set by you and your physical therapist. Thank you for your consideration, our staff and other patients whom may need your appointment time. HIPAA Privacy Authorization I,, give OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC, permission to share my information with Any member of my family These Individuals: Do not speak or share any of my information with family or friends, unless I give written/verbal permission Your information may be sent to healthcare providers, health insurance companies protected by the federal privacy regulations, and to the individual(s) of your choice. Your information may be: Transferred or utilized between the administration and professional staff Transferred from OPPT to the billing contractor who handles our billing. They have signed an agreement not to utilize your records other than those necessary to administer your insurance claim and pervade internal reports to OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC. You may refuse to sign this authorization and it will not affect your ability to obtain treatment. You may receive a copy of this authorization at the time of signing and/or revoke this authorization at any time by sending a written notificati0on to the office _. Printed Name of Patient or Guardian (seal) Signature of Patient or Guardian Date
6 Name: Date: HEADACHE DISABILITY INDEX INSTRUCTIONS: Please CIRCLE the correct response: 1. I have headache: [1] 1 per month [2] more than but less than 4 per month [3] more than one per week. 2. My headache is: [1] mild [2] moderate [3] severe INSTRUCTIONS: PLEASE READ CAREFULLY: The purpose of the scale is to identify difficulties that you may be experiencing because of your headache. Please check off YES, SOMETIMES, or NO to each item. Answer each item as it pertains to your headache only. YES SOMETIMES NO E1. Because of my headaches I feel handicapped. Δ Δ Δ F2. Because of my headaches I feel restricted in performing my routine daily Δ Δ Δ activities. E3. No one understands the effect my headaches have on my life. Δ Δ Δ F4. I restrict my recreational activities (e.g. sports, hobbies) because of my Δ Δ Δ headaches. E5. My headaches make me angry. Δ Δ Δ E6. Sometimes I feel that I am going to lose control because of my headaches Δ Δ Δ F7. Because of my headaches I am less likely to socialize. Δ Δ Δ E8. My spouse/significant other, or family and friends have no idea what I am Δ Δ Δ going through because of my headaches. E9. My headaches are so bad that I feel I am going to go insane. Δ Δ Δ E10. My outlook on the world is affected by my headaches. Δ Δ Δ E11. I am afraid to go outside when I feel a headache is starting. Δ Δ Δ E12. I feel desperate because of my headaches. Δ Δ Δ F13. I am concerned that I am paying penalties at work or at home because of Δ Δ Δ my headaches. E14. My headaches place stress on my relationships with family or friends. Δ Δ Δ F15. I avoid being around people when I have a headache. Δ Δ Δ F16. I believe my headaches are making it difficult for me to achieve my goals Δ Δ Δ in life. F17. I am unable to think clearly because of my headaches. Δ Δ Δ F18. I get tense (e.g. muscle tension) because of my headaches. Δ Δ Δ F19. I do not enjoy social gatherings because of my headaches. Δ Δ Δ E20. I feel irritable because of my headaches. Δ Δ Δ F21. I avoid traveling because of my headaches. Δ Δ Δ E22. My headaches make me feel confused. Δ Δ Δ E23. My headaches make me feel frustrated. Δ Δ Δ F24. I find it difficult to read because of my headaches. Δ Δ Δ F25. I find it difficult to focus my attention away from my headaches and on other things. Δ Δ Δ
PATIENT INFORMATION. Patient: S.S.# Address: D.O.B. Home Phone: Bus Phone: Male Female. Emergency contact: Relation to Patient: PH#
Massage 258 West 91 st Street, Suite 1-B Physical THERAPY EXPERTS, PLLC WELCOME 212-875-8345 T PLEASE FILL IN FORM COMPLETELY TO AVOID INSURANCE PAYMENT DELAY! PATIENT INFORMATION Patient: S.S.# Address:
Physical Occupational and Speech Therapy Patient Information Sheet
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THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:
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Medical History Questionnaire
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Ambulance/ER Report Medpay Claim # Auto Insurance Declarations Page Workman s Comp Claim # Health Insurance Card Medpay Claim #
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Sincerely yours, Rev. 06.10
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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.
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PATIENT REGISTRATION Date:
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Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,
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PATIENT INFORMATION EMERGENCY CONTACT LAST FIRST RELATIONSHIP REFERRAL SOURCE DOCTOR / REFERRING CLINICIAN: FAMILY MEMBER/FRIEND: INSURANCE:
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PATIENT REGISTRATION Date:
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PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED
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PATIENT /GUARDIAN SIGNATURE
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X Guarantor/Parent/Guardian Signature
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Patient History Information
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PATIENT INTAKE INFORMATION
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Nichol A. Moses, Psy.D., NCSP
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New Patient Registration Information
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Orthopedic Initial Questionnaire
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Dear Patient: Photo ID Insurance card(s) Prescription/referral for physical therapy Any Claim documentation (auto/w/c)
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For office use only: Start of Care: ICD-9 Codes: Patient Information: Name: Address: City: State: IL Zip: Patient of Birth: Policy Holders of Birth: of Injury or Onset of Symptoms: Home Phone: Work Phone:
PATIENT REGISTRATION
PATIENT REGISTRATION NAME: HOME ADDRESS: CITY, STATE, & ZIP CODE: HOME PHONE: CELL: WORK: SOCIAL SECURITY NUMBER: SEX: MALE/FEMALE DATE OF BIRTH: AGE: EMERGENCY CONTACT: RELATIONSHIP: EMERGENCY CONTACT
Patient Demographic Form
Patient Demographic Form Today s Date This document is part of your permanent record. By law, we are required to collect the following information from every patient treated in our facility. Please assist
Policies for Easter Seals South Carolina Therapy Services
Policies for Easter Seals South Carolina Therapy Services It is our goal to serve you and your child with excellence. Please carefully read through the following policies. 1. During or prior to your initial
RIDGEWOOD PHYSICAL THERAPY AND REHABILITATION CENTER PATIENT INFORMATION
RIDGEWOOD PHYSICAL THERAPY AND REHABILITATION CENTER PATIENT INFORMATION Today s date: / / EMAIL: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. SS#: - - Birth date: Sex: [ ]
PATIENT INFORMATION FORM
737 Pearl Street, Suite 108 Phone: 858.456.2114 Fax: 858.456.2103 www.abilityrehabsd.com PATIENT INFORMATION FORM Please print and complete ALL items. If an item doesn t apply, put N/A Patient Name: Age:
OFFICE POLICIES. Please note that NO controlled substance requests can be filled via phone as per DEA regulations. (initial)
OFFICE POLICIES Thank you for choosing Spencer Dermatology and Skin Surgery Center for your health care needs. We recognize that you have a choice in health care providers and we appreciate the trust that
Advanced Solutions Pain Management
Joseph Ho, M.D. Sabrina Shue, M.D. Patient Information Name: M F Age: Last, First, Middle (Circle One) DOB: SSN: Single Married Divorced Separated Widowed Address: City: State: Zip: Home Phone: Cell: Work:
PENNSYLVANIA PLASTIC SURGERY ASSOCIATES, P.C. Howard S. Caplan, M.D. Francine A. Cedrone, M.D. Account #
PENNSYLVANIA PLASTIC SURGERY ASSOCIATES, P.C. Howard S. Caplan, M.D. Francine A. Cedrone, M.D. Account # PATIENT INFORMATION QUESTIONNAIRE Patient Name Resp. Party/Spouse Address Address City, State, Zip
Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax)
PATIENT INFORMATION: Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax) Last Name: First: MI: Address: City:
Next Level Physical Therapy PC Patient Information
Next Level Physical Therapy PC Patient Information First Name M.I. Last Name Date of Birth SS# (if minor, leave blank) Student? F/T P/T NO Street Address Billing Address (if different) City State Zip Home
Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -
4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)
Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)
Patient Name: Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) (Last), (First) (Middle Initial) Address: City: State:
Garland s Christian Counseling Center
Garland s Christian Counseling Center : PERSONAL DATA Name: Email: Home Phone: Address: Cell Phone: Work Phone: (Street, City, Zip Code) DL #, ST & Exp : SS#: DOB: Sex: Please circle where we may leave
Athens Neuro & Balance Rehabilitation
Acknowledgement of Receipt Of Notice of Privacy Practices Patient Name & Address: I have a received a copy of the Notice of Privacy Practices for the above named practice. Signature For Office Use Only
Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email Address
PLEASE PRINT CLEARLY : NEW PATIENT FORM Name Last) (First) ( (M.I.) Birth Social Security Age Sex: M / F Home Address City State Zip Complaint/ Area to be treated Email Address Home Phone ( ) Drivers Lic
Cell Phone / Best Number To Reach You: Your e-mail address: Race: C AA Asian Other. Copay: Copay:
DUS Family Medical Practice, LLC 7525 Greenway Center Drive, Suite # 105 Greenbelt, MD 20770 Phone: (301)313-0425 Fax: (301)313-0435 Patient s Last Name: First Name: MI: Address: City: State: Zip Code:
PATIENT REGISTRATION FORM
GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:
IRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515
: / / Client Name: _ SSN: / / of Birth: Age: Sex: Male Female Address: City/State/Zip: Home Phone Number Is it okay to leave a message here? Y/N Work Number Is it okay to leave a message here? Y/N Cell
SOUTH COUNTY PHYSICAL THERAPY AND REHABILITATION CENTER, INC.
SOUTH COUNTY PHYSICAL THERAPY AND REHABILITATION CENTER, INC. 6767 9th Avenue Port Arthur, TX 77642 Ph: (409) 985-9365 Fax (409) 985-6315 I consent to treatment and I authorize payment of medical benefits
INTEGRATED PHYSICAL THERAPY a whole- istic approach to physical therapy
Patient s Name: D.O.B.: Age: Address: City: State: _ Zip Code: Home Phone #: Cell #: _ Business #:_ Social Security Number: E- mail Address: Referring Physician? _ How do you hear about us: Dr. Referral
DOB: // // Gender: Male Female. Home: Cell: Work:
Core Physical Therapy Clinics, LLC Paper Registration Form Patient Name Date DOB: // // Gender: Male Female Address: City State: Zip Code Home: Cell: Work: Email: Emergency Contact Employer: Name Insurance
Name: Sex: Male Female. Address: Apt#: Home #: ( ) Cell #: ( ) Other: ( ) DOB: Age: S.S. No. E-mail: Employer: Business # ( ) Occupation:
You deserve to be healthy. Life is a miracle and so are you. When you were created, you were given all the blue-prints, intelligence, tools, and systems to live an active healthy life. Unfortunately, your