HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I (340) P (340) F WELCOME
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1 HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I (340) P (340) F WELCOME We are pleased you have chosen us for your physical therapy needs. Our office is committed to providing you with the best possible experience and highest quality of care. We are here to help you in any way possible. We will bill directly to Workmen s Compensation, Veteran Administration, Vocational Rehabilitation, and other major insurance companies such as BC/BS of the Virgin Island, Cigna, United Health Care, Canada Life and Atlantic Southern. Major insurance companies may cover up to 80% of charges but you are required to pay for any amount that the insurance company may not pay. YOU ARE RESPONSIBLE FOR PAYMENT OF OUR SERVICES. IF YOUR INSURANCE COMPANY DOES NOT PAY FOR ANY REASON OR TAKES LONGER THAN 90 DAYS, YOU MAY BE REQUIRED TO PAY AND COLLECT FROM THEM YOURSELF. WE CHARGE THE 9% INTREST ALLOWED BY VIRGIN ISLANDS LAW ON ANY UNPAID AMOUNT AFTER 90 DAYS. We DO NOT bill attorneys or accept liens. If you have any difficulties with our policies, please arrange to discuss the matter with the Facility Director. THANK YOU FOR CHOOSING HORIZON PHYSICAL THERAPY ******************************************************************* Name Age DOB Physical Address Mailing Address Phone Alt. Phone Zip Code EMPLOYMENT STATUS Employer Social Security Number Occupation Employer s Number HOW WILL YOU PAY FOR YOUR SERVICES? Primary Insurance Subscriber s Name Patient Name Subscriber SSN Subscriber s DOB Subscriber s Place of Employment Did you meet your Deductible? What is your Copay? 1
2 IT IS VERY IMPORTANT THAT YOU COMPLETE THE FOLLOWING INFORMATION: What is your doctor s name? What is your doctor s number? Location/ type of pain and/ or limitations. Did you have an injury? Y N If yes: Was it work related? Y N Was it due to a motor vehicle accident? Y N What was the date of the injury? Has any other doctor, physical therapist or other medical professional treated you for this problem before? Y N If yes, who treated you, when were you treated and what did they do for treatment Your medical history (circle all that apply): Diabetes Asthma Hypertension/ High Blood Pressure Emphysema/ COPD Heart Disease Cancer (type) Sickle cell anemia Peripheral vascular disease Other: Please list any operations you have had Please list all medication that you take _ Non Medical History Marital status: unmarried married separated divorced other Do you work outside the home? If so, what type of work? Please list all activities and sports you participate in. Do you use tobacco products? Y N if yes please indicate which of the following apply Cigarettes pack(s) per day, for years Cigars daily/ weekly/monthly, for years Dip/ chew/ other Do you drink alcoholic beverages? Y N If yes Approximate frequency: drinks per day/weekly/monthly Are your right- handed or left- handed (circle one) 2
3 Your height: Weight: Questions regarding your general health; please circle any symptoms or conditions which you are currently experiencing or have recently experienced: Weight loss tingling in the hand or feet Urinary problems Weight gain Skin sores Allergies Fever Changes in eye sight Weakness Headache Shortness of breath Heartburn Palpitations Unusual bleeding Chest pain Menstrual problem Are you currently pregnant? Y N I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS CORRECT AND ACCEPT MY FINANCIAL RESPONSIBILITIES AS DEFINED ABOVE. FURTHER MORE, I CONSENT TO RECEIVE TREATMENT AT HORIZON PHYSICAL THERAPY AND PERMIT ITS EMPLOYEES AND ALL OTHER PERSONS CARING FOR ME IN WAYS THEY JUDGE BENEFICAL TO ME. I UNDERSTAND THAT THIS CARE CAN INCLUDE EVALUATION, TESTING AND TREATMENT AND NO GUARANTEES HAVE BEEN MADE TO ME ABOUT THE OUTCOME OF THIS CARE. Patient s Signature Date I HEREBY AUTHORIZE HORIZON PHYSICAL THERAPY TO RELEASE ANY/ ALL INFORMATION REGARDING MY MEDICAL HISTORY, TREATMENT, SYMPTOMS EXAMINATION, RESULTS OR DIAGNOSIS TO ANY PERTINENT INSURANCE COMPANIES, PHYSICIANS, OR ANY OTHER RESPONSIBLE PARTIES. Patient s Signature Date I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO KNOW MY ELIGIBILTY FOR BENEFITS WITH MY INSURANCE COMPANY. I UNDERSTAND THAT I AM RESPONSIBLE FOR THE COST OF SERVICES RENDERED AT HORIZON PHYSICAL THERAPY IF MY INSURANCE DOES NOT PAY. Patient s Signature Date 3
4 NOTICE OF PRIVACY PRACTICES HORIZION PHYSICAL THERAPY ABBREVIATED VERSION THIS NOTICE DESCRIBED HOW MEDICAL INFORMATION ABOUT YOU WILL BE USED AND DISCLOSED AND HOW YOU CAN GET ACESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Horizon Physical Therapy is required by law, to maintain the privacy an confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information. This is an abbreviated notice, but the full notice is available for your review if you desire. Disclosure of Your Health Information Treatment We may disclose your health care professionals within our practice for the purpose of treatment payment or health care operations. Payment We may disclose your health information to your insurance provider for the purpose of payment or health care operations. Workers Compensation We may disclose your health information as necessary to comply with the State Workers Compensation Laws. Emergencies We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care, about your medical condition or event of an emergency or of your death. Complaints Complaints about your privacy right or how Horizon Physical Therapy has handled your health information should be directed to Jennifer Payne, PT. This notice is effective as of 04/14/03 I have read this abbreviated Notice of Privacy Practices and understand my rights contained in this notice. By way of my signature, I provided Horizon Physical Therapy wit my authorization and consent to use and disclose my protected health information for the purpose of treatment, payment, and health care operations as described in the notice of Privacy Practices. Patients Name (print) Signature of patient Authorized Facility Signature _ Date _ Date 4
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Patient Registration Form MRN #: Patient Name: Provider: Sort ID: DOB: Date: Address Home Phone Cell Phone Work Social Security Number Date of Birth Male Female E-mail Address Is your visit today due to
Welcome to Tri-State Rehab Services
Welcome to Tri-State Rehab Services Ashland Ironton Jackson Louisa New Boston Westmoreland Thank you for choosing our facility. To help us meet all your physical therapy needs, please fill out forms completely
PROUGH CHIROPRACTIC 3402 Washington Rd., Suite 201 McMurray, PA 15317 PATIENT INFORMATION & CONDITION FORM
Today's Date: / / PROUGH CHIROPRACTIC PATIENT INFORMATION & CONDITION FORM Patient Name: Birth Date: / / Age: Gender: F M CURRENT ADDRESS Street City State Zip Phone ( ) Cell Phone ( ) E Mail Address If
PATIENT REGISTRATION
Evan Wolf, MD PhD Jacob Frank, OD PATIENT REGISTRATION Welcome to our office. In order to serve you properly, we will need the following information. (Please Print) Patient First Name Middle Initial Last
PATIENT INFORMATION. Age: Street address: Email: Primary Phone no.: City: State: ZIP Code: P.O. box: Occupation: Employer: Employer phone no.
(Please Print) Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Birth date: Age: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Sex: M F Street address:
þ Bring your completed forms with you. þ Arrive 10 to 15 minutes early the first day.
BRIAN T. WILLIAMS M.S., P.T. KELLY GAMMAGE P.T. CHRISTOPHER OLIVEIRA P.T. SARA G. RIEDEL P.T., C.S.C.S. ORTHOPEDIC SPORTS PHYSICAL THERAPY EVALUATION & TREATMENT 155 HILL STREET MILFORD CT 06460 WWW.CENTERREHAB.COM
WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
HIRSHFIELD DENTAL CARE 50 NORTH ST. MEDFIELD, MA 02052 Today s date WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
New Patient Form Please print clearly
New Patient Form Today s Date: Name: Last First MI Preferred name to be called: Email: Address: Street City State Zip DOB: Age: Sex: SSN#: - - Please check a box for the preferred # to call to confirm
How To Write A Medical History Questionnaire For An Aransas Plastic Surgery
Arkansas Plastic Surgery O David H. Bauer, M.D. O Gary E. Talbert, M.D. Appointment Date Patient Information INFORMATION FOR CASE HISTORY FILE Patient s Name: SS# First Middle Last Date of Birth: Patient
FAIRBANKS PHYSICAL THERAPY
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
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH:
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVERS LICENSE NUMBER: STATE: EMAIL ADDRESS: MARITAL STATUS: ( ) SINGLE ( )
Joint Effort Rehab, LLC New Patient Forms
Patient Information DEMOGRAPHICS Joint Effort Rehab, LLC First Name: MI: Last Name: Sex: M F Home Phone: Work Phone: Cell Phone: SSN: of Birth: Email: Referring Physician: Employer Name: Primary Insurance
Medical Insurance and Vision Plans
Notice of Privacy Practices Methods of Payments No Insurance? No problem! Claremore Eye Associates offers a discount for all non- insurance patients for their vision exam. We also accept all major credit
New Patient Registration Form
New Patient Registration Form PLEASE PRINT How did you learn about our practice? DATE Physician Relative Friend Website Phone book Newspaper Other Patient s Full Name Age Home Address City State Zip Home
LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP OCCUPATION EMPLOYER/SCHOOL WORK PH
PLEASE PRINT PATIENT INFORMATION TODAY S DATE: LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP E-MAIL HOME CELL OCCUPATION EMPLOYER/SCHOOL WORK SOCIAL SECURITY NO SEX: M / F DATE OF BIRTH MARITAL STATUS:
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medicare Insurance Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning