Dear Patient: Photo ID Insurance card(s) Prescription/referral for physical therapy Any Claim documentation (auto/w/c)
|
|
- Osborne Briggs
- 8 years ago
- Views:
Transcription
1 7500 Hanover Pkwy Ste. 103 Greenbelt, MD Phone: Fax: Kenilworth Ave. Ste Riverdale MD Phone: Fax: Dear Patient: Attached is your complete Patient Application. We have included a summary of each section to help you better understand what information is being requested. Please read, complete in its entirety, and bring this application with you to your appointment, along with: Photo ID Insurance card(s) Prescription/referral for physical therapy Any Claim documentation (auto/w/c) Section One This part if the application if for your personal demographic information. Legibly, in block letters, please enter all the requested information. Note: Enter your name as it is written on your health insurance card Guarantor name should be entered if the patient is a minor. Please enter your address if you have one. This is used for contact purposes and for holiday/birthday cards etc.
2 Section Two This section refers to the reason you are coming to therapy. Note: Please enter the physician who referred you to physical therapy Emergency contact information Section Three Auto Accident or Workers Compensation If you have come to physical therapy because of an auto accident, a workers compensation (W/C) claim or you have an attorney assigned to your case, please complete this section. Section Four This section should be completed if there is an attorney assigned to your case. Section Five This section must be completed if you have health insurance. Even if you are using an auto claim or W/C claim, we MUST have your health insurance on record. Section Six All patients who either DO NOT have health insurance or wish to pay out-of-pocket for therapy treatment, must initial this section. Section Seven The purpose of section is to inform the therapist of your medical history. Please complete this section and include a separate list of medication you currently take, if applicable.
3 Section Eight. Financial Policy Statement. This section explains that: a) Regardless of your insurance type (health insurance, auto claim, W/C claim, attorney case, selfpay, that you understand what your accountability and responsibility is in each situation. b) PTSMC has verified your insurance benefits and eligibility and we are disclosing your financial responsibility, per your insurance plan guidelines. c) You, the patient, agree to be treated here at PTSMC by a licensed therapist. d) You, the patient, agree to assign all entitled medical benefits to PTSMC and that you authorize the release of information to any associated insurance, third party or legal entity. Section Nine The HIPPA Disclosure explains who PTSMC has authorization to release information to as well as YOUR privacy rights. Please read. Section Ten PTSMC has a very strict No-Show (NS) and Cancellation (Cx) policy. Please read this section carefully and sign. Section Eleven. Attorney Authorization If there is an attorney assigned to your case (auto, W/C), this form must be executed by you and your attorney, verifying the attorney s involvement and responsibility as well as your authorization. Please sign and date this form and submit to us to have it signed by your attorney.
4 Section Twelve The Personal Injury Protection (PIP) Disclosure fully explains the procedure that needs to be followed in all auto accident cases. Section Thirteen The Pain chart is simply a body drawing that gives the therapist a quick visual of the location of your pain and the type of pain sensations you are experiencing.
5 7500 Hanover Pkwy Ste. 103 Greenbelt, MD Phone: Fax: Kenilworth Ave. Ste Riverdale MD Phone: Fax: PATIENT INFORMATION- SECTION ONE: PATIENT DEMOGRAPHICS Social Security#: - - Patient Name: Address: City: State: Zip: Guarantor Name (if applicable): Appointment Date: / / Day Time Phone:( )- - Birth Date: / / Age: Sex: Marital Status: Phone: Address: Primary Care Physician/ PCP: Work Phone:( )- - PCP's Phone: ( )- - *How did you hear about our facility? ======================================================================================= SECTION TWO: REFERRAL INFORMATION Name of physician who referred you to physical therapy: Referring physician s Phone: ( ) - - Fax: ( )- - Accident/Injury/Onset Date: / / Reconstructive Surgery: Y or N Emergency Contact: Relationship: Contact Phone: ( )- - SECTION THREE: AUTO ACCIDENT OR WORKERS COMPENSATION CASES 3A) Is this an Auto Accident claim? Y N If Yes, skip to 3B. If No, skip to (3vii) 3B) Accident/Injury Date: 3C) What is YOUR primary auto insurance company s name? 3Ci) Your auto claim number: 3cii) Claim adjuster s name:
6 3Ciii) Claim adjuster s phone and fax: 3civ) Has your adjuster approved physical therapy visits? Keep in mind that PTSMC MUST have proper verification from the adjuster that this claim is approved BEFORE you can be scheduled for an appointment. 3V) Have you submitted your PIP application? Y N. Please refer to Section 10 for the PIP Disclosure. 3VI) Is this a W/C claim? Y N 3vii) W/C claim number: 3viii) W/C Case adjuster Name: 3ix) W/C case adjuster Phone: ( ) - - Fax: ( ) - - SECTION FOUR LITIGATION CASES Is there an attorney assigned to this case: Y N If yes, please print the name of the law firm / attorney: Attorney Phone: ( )- - Fax:( )- - Have you signed PT&SMC s Attorney Authorization (AA) form attached? Y N SECTION FIVE HEALTH INSURANCE If you do NOT have health insurance and wish to pay out-of-pocket, skip to section 6. -PRIMARY INSURANCE- Primary Health Insurance: Policy #: Group#: Insured Name: Subscriber Name: Subscriber DOB: Insurance Phone: ( )- - ext.: Fax ( )- - -SECONDARY INSURANCE- Secondary Health Insurance: Policy #: Group#: Insured Name: Subscriber Name: Subscriber DOB: Insurance Phone: ( )- - ext.: Fax ( )- -
7 SECTION 6 SELF-PAY PATIENTS Please initial this section. I do Not have health insurance. I understand that the PTSMC self-pay charge per visit, is $75.00 I understand that this payment MUST be made AT THE TIME OF SERVICE, at each appointment. NO EXCEPTIONS.
8 Physical Therapy & Sports Medicine Center SECTION 7 PATIENT MEDICAL HISTORY Patient's Name: Birth Date: / / Age: Cell or Home Phone:( )- - Accident/Injury/Onset Date: / / Have you had surgery for this injury? YES NO (if yes) Number of Surgeries: Type of Surgery: Took Place in: Hospital Surgery Center Other: * Current Level of Pain Between 0-10 (0 being no pain, 10 being pain requiring ER care) * Are You Currently Taking Any Prescription or Non-Prescription Medication? YES NO List Medications: Have you had any of the following medical or rehabilitation services for this injury/episode? YES NO YES NO Chiropractor CT Scan EMG/NVC General Prac. Massage Therapy MRI Myelogram Neurologist Occupational Therapy Orthopedist Physical Therapy Podiatrist ER Care X-Rays Other: -Do you now have or have you ever had ANY of the following?- YES NO YES NO Asthma, Bronchitis, or Emphysema Severe or Frequent Headaches Shortness of Breath/Chest pain Vision or hearing difficulties Coronary Heart Disease or Angina Numbness or Tingling Do you have a pacemaker? Dizziness or Fainting High Blood Pressure Weakness Heart Attack or Surgery Hernia Stroke/TIA Blood Clot/Emboli Bowel or Bladder Problems Varicose Veins Epilepsy/Seizures Allergies Thyroid Trouble/Goiter Any Pins or Metal Implants Anemia Joint Replacement Infectious Disease Diabetes Emotional/Psychological Problems Cancer or Chemotherapy/Radiation Arthritis/Swollen Joints Osteoporosis Gout Are You Pregnant? Sleeping Problems/Difficulties Do You Smoke? Leg/Ankle/K nee/foot Injury/Surgery Elbow/Hand/ Shoulder Injury Surgery Back/Neck Injury/Surgery List any other information that would assist us in your care Are you aware of what your diagnosis is? YES NO Based upon your awareness, what are your expectations/goals while in this program? 7500 Hanover Pkwy Ste. 103 Greenbelt MD Phone: Fax: Health Center Dr. Ste. 201 Bowie MD Phone: Fax: Georgia Ave Ste. 100 Olney MD Phone: Fax: Kenilworth Ave. Ste Riverdale MD Phone: Fax:
9 SECTION Hanover Pkwy Ste. 103 Greenbelt, MD Phone: Fax: Kenilworth Ave. Ste Riverdale MD Phone: Fax: FINANCIAL POLICY STATEMENT We bill your insurance carrier solely as a courtesy to you. You are responsible for the entire bill when the services are rendered. We require that arrangements for payment of your estimated share be made today. If your insurance carrier does not remit payment within 60 days, the balance will be due in full from you. In the event that your insurance company requests a refund of payments made, you will be responsible for the amount of money refunded to your insurance company. In the event your company establishes an internal usual and customary fee schedule, you will be responsible for the difference remaining. If any payment is made directly to you for services billed by us, you recognize an obligation to promptly remit same to Physical Therapy & Sports Medicine Center. The above does not apply for those patients that are considered Worker s Compensation. However, be advised if you claim Workers Compensation benefits and are subsequently denied such benefits, you may be held responsible for the total amount of charges for services rendered to you. I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees and attorney fees. ESTIMATED INSURANCE BENEFITS: Estimated patient payment Arrangements for payment of patient s share NOTE: Estimated coverage information is provided as a courtesy to our patients but is not intended to release them from total responsibility for their account balance. The above information has been read and explained to me. Patient/Guardian/Responsible Party Center Representative/Witness CONSENT FOR CARE AND TREATMENT Date Date I, the undersigned, do hereby agree and give my consent for Physical Therapy & Sports Medicine Center to furnish medical treatment to (please PRINT name) Considered necessary and proper in diagnosing or treating his/her physical and mental condition. Patient/Guardian Signature Date: BENEFIT ASSIGNMENT/ RELEASE OF INFORMATION I, hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled, including Medicare, Medicaid, private insurance and third party payers to Physical Therapy and Sports Medicine Center. A photocopy of assignment is to be considered as valid as the original. I, hereby authorize said assignee to release a information necessary including Medical Records to secure payment. Patient/Guardian Signature Date: 1
10 7500 Hanover Pkwy Ste. 103 Greenbelt, MD Phone: Fax: Kenilworth Ave. Ste Riverdale MD Phone: Fax: SECTION 9 Patient Authorization and Disclosure of Protected Health Information Statement of Privacy Act. We may disclose your health care information: 1. To other healthcare professionals within our practice for the purpose of treatment, payment or health care operations. 2. To insurance provider for the purpose of payment or health care operations. 3. To comply with State Workers Compensation laws 4. To public health employees for preventing/controlling disease and reporting infectious exposures. 5. In the course of any administrative of judicial proceeding or law enforcement purposes Under HIPPA Federal Privacy law, you have the right to: 1. Request restrictions on certain uses of your health care information 2. Inspect and copy your healthcare information 3. Receive an accounting or disclosures of your protected health information made by us. 4. You have a right to a paper copy of this Notice of Privacy Practices at any time, upon request. We reserve the right to amend this notice of Privacy Practices at any time in the future. We are required by law to maintain the privacy of your healthcare information. If you have any questions regarding this notice or if you want more information about your privacy rights, please contact us at My signature indicates my authorization and consent for Physical Therapy and Sports Medicine Center to use and disclose my protected health care information for the purposes of treatment, payment and healthcare operations as described above. Patient s Name (PRINT): Patient s Signature: Date:
11 7500 Hanover Pkwy Ste. 103 Greenbelt, MD Phone: Fax: Kenilworth Ave. Ste Riverdale MD Phone: Fax: SECTION 10 Cancellation and No-Show Policy We ask that you help us to serve you by keeping your scheduled appointment. Appointments that are missed or cancelled at the last minute are not able to be given to other patients who need an appointment. You must be on time, so that you can be given the full benefit of your therapy session. Any patient who arrives more than 15 minutes late may not be seen by the therapist, AND a cancellation charge of $50.00 will be applied. If a patient is running late, it is asked that you call our office and let us know so that we can inform the therapist. PT&SMC requires at least 24 hours-notice for appointment cancellation. Any appointment that is cancelled the same day or within less than 24 hours will result in a $50.00 cancellation fee. This fee must be paid before one can be checked in at the next appointment. No-shows are a $50 charge Understand that if you do not show up to an appointment, without notice to our office, any future scheduled appointments will be removed from the system. The $50 fee must be paid in order for the next appointment to be scheduled. Three episodes of not attending physical therapy (no-show) will result in patient discharge from therapy. In the case of medical emergency, proper documentation (doctor s note etc.) must be provided. *No exceptions!* The above information has been read and explained to me. I understand the office policy. Patient: Date 1
12 7500 Hanover Pkwy Ste. 103 Greenbelt, MD Phone: Fax: Kenilworth Ave. Ste Riverdale, MD Phone: Fax: Section 12 Personal Injury Protection (PIP) Disclosure If you have been involved in an auto accident and have come to our facility with a filed claim, by law, PT&SMC MUST bill your PIP insurance. In order for your automobile insurance company to pay physical therapy benefits from your Personal Injury Protection or PIP policy, you MUST fill out the PIP Application. You should have received an application from your insurance company in the mail. If not, please contact your PIP case adjuster to make sure it is filled out. If you have not completed your PIP application, your visits will NOT be paid for through your auto claim. You need to contact your insurance company and complete the PIP application in order to become eligible for the PIP policy to pay your physical therapy bills. Your attorney is NOT responsible for completing your PIP application. If you have an auto accident claim, this is the order in which your physical therapy claims will be processed: 1. PIP insurance will be billed, per the claim information provided. 2. In the event that PIP exhausts, your health insurance will be billed next, with a copy of the exhaustion letter from the PIP insurance company. (Please understand that once your health insurance is being billed, you will be responsible for payment in accordance with your health insurance plan deductibles/co-pay/co-insurance) 3. If there is an attorney assigned to the case, an AA form MUST be executed and the attorney will be sent a statement reflecting any visits that have not been paid for. 4. If PIP exhausts and there is no health insurance, attorney will be billed the balance. If PIP exhausts and there is no health insurance and no attorney, the patient is fully responsible for the balance of payment. Acknowledgement Disclosure: By signing this agreement you indicate your consent to the term and conditions as are set forth herein and that translation of this agreement in Spanish or any other language is not necessary. Once signed, this disclosure shall become binding in all terms and respects and enforceable in State of Maryland, U.S.A. Patient Name (PRINT) Patient Signature Date 1
13 7500 Hanover Pkwy Ste. 103 Greenbelt, MD Phone: Fax: Kenilworth Ave. Ste Riverdale MD Phone: Fax: SECTION 11 Attorney Authorization I, the undersigned attorney for patient, hereby agree to make payment directly to Physical Therapy & Sports Medicine Center when the above patient s case is closed. I the undersigned attorney also agree to advise Physical Therapy & Sports Medicine Center in writing within ten days of: 1. Written or verbal request for updated status of the case 2. The settlement of the case or any other significant change in status, especially if this precluded or alters payment of Physical Therapy & Sports Medicine Centers, services professional fees by the law firm or other parties involved in the case. 3. For any settlement amount less than PTSMC s patient statement amount, a paper trail must be provided by the third party, to PTSMC management. Attorney s Signature: Date: Patient s Signature: Date:
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:
More informationHI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy)
HAWAII PHYSICAL THERAPY INC. -- PATIENT REGISTRATION FORM Please fill out this form to register as a patient of Hawaii Physical Therapy Inc. All fields with an asterisk (*) are REQUIRED. We cannot register
More informationAON Physical Therapy & Wellness
AON Physical Therapy & Wellness PATIENT REGISTRATION Patients First and Last Name Intake Taken By- Appointment Date / Therapist Date- Date of Birth: Is the patient Under 18? If so, who is the guarantor?
More informationNext 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
More informationHAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C.
Consent for Care and Treatment I, the undersigned, do hereby agree and give my consent for HAND & ORTHOPEDIC PHYSICAL THERAPY ASSOCIATES, A NJ P.C., to provide Care and Treatment to considered necessary
More informationHand & Orthopedic Physical Therapy Associates, P.C.
Patient Name: Hand & Orthopedic Physical Therapy Associates, P.C. Date of Birth: ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN) NOTE: If Medicare doesn t pay for items listed below, you may have to pay.
More informationMILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: M F 6) Date of Birth (DOB): / / 7) Marital
More informationMedical History Questionnaire
Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of
More informationPATIENT 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
More informationBody Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,
Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia
More informationOrthopedic Initial Questionnaire
Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
More informationJaworski Physical Therapy, Inc. Private Health Insurance. Worker s Compensation (complete the following)
Jaworski Physical Therapy, Inc. Patient Name: Date: Private Health Insurance Name of Private Health Insurance: ID#: Group#: Cardholder Name: Cardholder Date of Birth: Relationship to Patient: Phone: Address
More informationTHANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS!
THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS! Please complete and sign all of the enclosed forms. Bring these forms, your physician s referral if required and any other documents required
More informationPlease fill out the new patient paperwork and bring it with you, along with a photo ID and health insurance or Medicare card.
Dear Patient, Thank you for choosing San Antonio Center for Physical Therapy for your rehabilitation needs. We want your time with us to be a positive experience, one that leads you down a road of successful
More informationOrthopedic Initial Questionnaire. Date: Weight:
Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
More informationTHINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:
THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: Social Security Number: Employment Status: Marital Status: Emp Unemp
More informationDATE 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.
More informationName 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
More informationAdvantage Physical Therapy Patient Registration
Appointment Date/Time: Therapist: Advantage Physical Therapy Patient Registration ****Please note ALL patients are required to have a prescription for Physical Therapy from a referring Physician prior
More informationINTEGRATED 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
More informationHow To Get A Physical Therapy At West Point Physical Therapy Center
Palmdale (Main) 1115 West Ave. M-14 Palmdale, CA 93551 (661)265-0060 To our workers compensation patients: Cathedral City 68-845 Perez Rd., Ste. H6-H7 Cathedral City, Ca 92234 (760)328-0292 California
More informationNew Patient Registration Information
New Patient Registration Information ADAMS COUNTY LOCATIONS YORK COUNTY LOCATIONS Adams Health Center........ (717) 339-2620 Apple Hill................ (717) 741-8240 Aspers Health Center........ (717)
More informationPatient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
More informationRIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form
Intake Form : Personal Information please print clearly Name: last first middle initial Home Address: Home Telephone: ( ) Cell Phone: E-Mail Address: Social Security #: of Birth: Age: Sex: M F Marital
More informationWelcome to Back Country Physical Therapy, Intake Form
Welcome to Back Country Physical Therapy, Intake Form Patient Information: Name: Social Security #: Sex (Circle): M / F Address: City: State: Zip: Home Phone: Birth date: Age: Marital Status (Circle):
More informationHouston Healthcare Therapy Agreement
Houston Healthcare Therapy Agreement We will do our best to: Begin all sessions on time Explain your treatment program and progress to you Accommodate your schedule Be consistent with your therapist and
More informationPersonal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
More informationST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION
Outpatient Services 2381 Lawrenceville Road 609-896-9500 voice Patient Name: Account #: ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION Your first day of outpatient
More informationCAMARILLO AQUATICS AND REHABILITATION SERVICES
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
More informationPATIENT INSURANCE AUTHORIZATION WORKSHEET
PATIENT INSURANCE AUTHORIZATION WORKSHEET We accept all insurances that have in-network and out-of-network benefits. If you do not have insurance benefits for physical therapy, please call us at 858-457-3545
More information11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509
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
More informationIf you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment.
Welcome to POST Physical Therapy Brookline. We strive to provide our patients with excellent service and quality care. Our commitment to your well-being and health care is something that we at POST Physical
More informationPRO SPORTS THERAPY, INC. (P.S.T.)
Dear Patient, Thank you for choosing Pro Sports Therapy. Enclosed is the paperwork that you will need to complete and bring with you for your physical therapy evaluation. Please arrive at least 15 minutes
More informationMVA New Patient Paperwork
Please Complete Entire Form MVA New Patient Paperwork Patient Name: M F Today s Date / / Address: Employer: _ City, State, Zip: Address: Home Phone: ( ) City, State, Zip: Cell Phone: ( ) Work Phone: (
More informationEXCEL PHYSICAL THERAPY, INC.
EXCEL PHYSICAL THERAPY, INC. Medical History Form Name: Date of Birth: Date: Are you employed? YES NO Right Handed Left Handed If NO, last day worked? Do you smoke? YES NO #of packs/day Occupation: Height:
More informationDEL MAR PHYSICAL THERAPY Patient Information
PLEASE PRINT CLEARLY DEL MAR PHYSICAL THERAPY Patient Information Name Birthdate Last First M.I. MM/DD/YYYY Age Sex M / F Marital Status SS# Address City Zip Phone ( ) Work ( ) Cell ( ) Email **********************************************************************************
More informationBIRTHDATE - - AGE SEX EMERGENCY CONTACT PHONE( )
PATIENT INFORMATION SOCIAL SECURITY # MARRIED SINGLE WIDOW DIVORCED NAME Last First MI HOME ADDRESS BILLING ADDRESS ACCT# DRIVER S LICENSE# BIRTHDATE - - AGE SEX CITY STATE ZIP CITY STATE ZIP PHONE HOME(
More informationPACIFIC PHYSICAL THERAPY 14650 Aviation Blvd., Suite 200 Manhattan Beach, CA 90250. Referring Doctor: PLEASE PRINT CLEARLY Email Address:
PACIFIC PHYSICAL THERAPY 14650 Aviation Blvd., Suite 200 Manhattan Beach, CA 90250 Date: Referring Doctor: PLEASE PRINT CLEARLY First Name: Last Name: Height: Address: City, St., Zip:_ Email Address: _
More informationLast Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Preferred Contact Method: Home Ph Mobile Ph Text E-mail
More information1455 West Fair, Marquette, MI 49855 Phone - 906.226.0574 // Fax - 1.888.347.1135 // info@mqtrehab.com
To our valued patients, In order to speed up the registration process and begin your treatment as soon as possible, please complete the forms listed below and bring the proper documentation to your first
More informationPATIENT /GUARDIAN SIGNATURE
PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: Date: / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S. #: - - Home Phone: ( ) - Alternative Phone (Cell, Pager):
More informationHow To Pay For Care At A Clinic
WELCOME TO THE HUMAN PERFORMANCE AND REHABILITATION CENTERS, INC. Welcome to Human Performance and Rehabilitation Centers, Inc. The following information will give you a better understanding of our payment
More informationName: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
More informationPhysical Therapy Services Medical History Form
Physical Therapy Services Medical History Form Last Name First Name DOB Age Diagnosis: Physician: Check Yes or No. If yes, please explain in the space provided. Yes No Are you pregnant? Yes No Currently
More informationWelcome 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
More informationLAST 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:
More information4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944
4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944 Dear Patient, Your insurance may pay your total bill for services rendered by Pilates People Torrey Hills.
More informationREHAB RESOURCES, INC. CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over)
CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over) Rehab Resources, Inc. is a certified agency that provides outpatient therapy services. Occupational, Physical,
More informationPatient/Guardian Signature Witness Signature
Today s Date Full Name Date of Birth Gender M F Social Security # Email * Home Address City State Zip Home Phone Work Phone Cell Phone Patient Employer Job Title Insurance Subscriber Subscriber Birthdate
More informationWilliam O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737
William O. Reed, Jr. M.D., P.A. 9119 W. 74 th Street, Suite 354 Overland Park, KS 66204 913-432-7200 Fax: 877-492-3737 Workers Compensation Form First Name MI Last Name Sex Date of Birth Social Security
More informationPATIENT 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:
More informationPROUGH 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
More informationDOB: // // 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
More informationSpecializing in back and neck pain, sports medicine, and joint injuries
www.rehabissaquah.com 425-394-1200 Fax 425-394-0100 1495 NW Gilman Blvd Ste 4 Issaquah, WA 98027 Dear New Patient: We look forward to meeting you and assisting with your medical care. In order to provide
More informationINTEGRATED PHYSICAL THERAPY A Holistic 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: Height: Weight: Referring Physician? Status: Married/Single/Other/Full
More informationReferring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:
Patient Information Referred By: Referring Physician: Patient Name: Appointment Date: Time: Last First Middle Int. Date of Birth: SS#: Street Address: City/State/Zip: Phone Numbers: Home: Work: Cell: Email:
More informationLOUISIANA PHYSICAL THERAPY CENTERS OF PINEVILLE, LLC 1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527
1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527 Patient Information Name First Middle Last Address City State Zip Phone Other Contact Email Social Security # DOB
More informationMade to Move Physical Therapy, Inc. 615 N Nash St., Ste # 306 El Segundo, CA 90245 310.535.0008
Name Last First MI Date Current/Permanent address City State Zip Phone H W Cell Email Address: Marital Status Single Married Other Date of Birth: Age: Gender Male Female Spouses DOB: Employer Occupation
More informationIMS Allergy & Immunology New Patient Registration Sheet. Personal Information
Personal Information Today s : Patient First Name: Initial: Last Name: DOB: Age: Social Security #: E-mail: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Gender: M F Language: ENGLISH
More informationPraxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medical 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 our professional
More informationPatient Information: In Case of Emergency: Physician: Insurance:
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:
More informationPACIFIC PHYSICAL THERAPY & SPORTS REHABILITATION HERMOSA BEACH
PACIFIC PHYSICAL THERAPY & SPORTS REHABILITATION HERMOSA BEACH PATIENT INFORMATION Patient Name: Address: Telephone: E-mail address: Birthdate: SS#: Employer: Occupation: Home Cell Work Gender: Male Female
More information920 NE 112 th Avenue, Suite 103, Vancouver, WA 98648 Phone: 360-567-2002 Fax: 360-567-2005 www.timberlinept.com
920 NE 112 th Avenue, Suite 103, Vancouver, WA 98648 Phone: 360-567-2002 Fax: 360-567-2005 www.timberlinept.com Thank you for selecting Timberline to be a part of your rehabilitation. Below we have condensed
More informationJoint 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
More informationX Guarantor/Parent/Guardian Signature
Patient Name: Last First Address City State Zip Phone# (C) (H) (W) Date of Birth Social Security# (REQUIRED FOR BILLING) If Patient is a Minor, a Parent s Name & Social Security# are Required Emergency
More informationþ 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
More informationLAS VEGAS PAIN INSTITUTE & MEDICAL CENTER, L.L.C.
LAST NAME: FIRST NAME: DOB: / / AGE: MARITAL STATUS: SEX: M F SSN: - - HOME#: CELL#: WORK#: STREET ADDRESS: CITY: STATE: ZIP: EMPLOYER NAME & ADDRESS: SPOUSE S NAME: DOB: / / SSN: - - WORK#: EMPLOYER NAME
More information*WELCOME TO OUR OFFICE*
*WELCOME TO OUR OFFICE* WE FIND THAT COMMUNICATION WITH OUR PATIENTS REGARDING OUR BUISNESS OFFICE POLICIES ASSISTS US IN PROVIDING YOU THE BEST SERVICE. THEREFORE WE HAVE PROVIDED A HIGHLIGHT OF SOME
More informationDr. Brett Haderlie, D.C. Patient Information (Please Print)
CONNECT CH I ROPRAC TIC Dr. Brett Haderlie, D.C. Patient Information (Please Print) Thank you for choosing our practice for your chiropractic needs. Name SS/HIC/Patient ID# Address City State Zip Birthdate
More informationPATIENT REGISTRATION
Orthopedic & Sports Therapy Center PATIENT REGISTRATION NAME DATE OF BIRTH SSN# FIRST MI LAST PHONE INFO: HOME BEST WAY TO CONFIRM APPOINTMENTS WORK CALL TEXT EMAIL MOBILE (TEXT) MOBILE CARRIER EMAIL ADDRESS
More informationACE PHYSICAL THERAPY & SPORTS MEDICINE INSTITUTE PATIENT REGISTRATION
ACE PHYSICAL THERAPY & SPORTS MEDICINE INSTITUTE PATIENT REGISTRATION ALEXANDRIA FAIRFAX FALLS CHURCH LEESBURG HERNDON TYSONS CORNER PATIENT INFORMATION (Please Print Clearly) Name Last First Middle of
More informationMVA/ PI Registration Form. Is this accident work related? YES or No If yes, stop here and notify front desk for different forms.
MVA/ PI Registration Form Is this accident work related? YES or No If yes, stop here and notify front desk for different forms. Date: Patient # Patient Name: DOB; Gender: M or F SSN Address: City/State:
More informationHow To Contact A Doctor From A Doctor'S Office
Anthony S. Lombardi, MD, FACS Nilla Defazio, PA C Jessica Henderson, PA C PATIENT INFORMATION Date Patients Last Name First Name M.I. Suffix(i.e,Jr.,Sr.) Street Address City State Zip Code ( ) ( ) M S
More informationPATIENT INFORMATION (Please Print Clearly)
PATIENT INFORMATION (Please Print Clearly) Patient Name (Full): Address: City: State: Zip: Birthdate: EMAIL: Date of Injury: Date of Surgery Cell phone: Home Phone: Work Phone: Sex: M F Marital Status:
More informationHands-On Care Physical Therapy P.C PhysioCare Physical Therapy P.C EXPLANATION OF PROCEDURES
EXPLANATION OF PROCEDURES Welcome to our practice. You are here because you have been referred to us by your doctor for Physical Therapy. Physical Therapy is defined as: The evaluation, treatment or prevention
More informationNorth Country Holistic Care Center PATIENT REGISTRATION FORM. Patient Information. Name: Address: City: State: Zip: Email
PATIENT REGISTRATION FORM Patient Information Name: Address: City: State: Zip: Telephone #: Home: Cell: Email Date of Birth: Age: Sex: M F Social Security #: - - Referred by: Employment Information Employer:
More informationStreet Address (Students-Permanent Address): Apt #: City: State Zip Birthdate Age: Sex: M/F. Home Phone Business Phone Cell Phone Social security #
CARR PHYSICAL THERAPY CENTER Patient's First Name Mi: Last Name PATIENT INFORMATION FORM Street Address (Students-Permanent Address): Apt #: City: State Zip Birthdate Age: Sex: M/F Home Phone Business
More informationDo you have private medical insurance (i.e. Blue Cross, Sun Life, Great West Life)? Yes
PERSONAL INFORMATION: The information in this section has remained unchanged from my last visit with CORE Physiotherapy & Rehabilitation Centre Inc. Last Name: DOB: First Name: Health Card Number: Address:
More informationRIDGEWOOD 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: [ ]
More informationHow To Get A Medical Checkup
NAFISA TEJPAR, M.D., F.A.C.S. 2501 N. Orange Ave, Ste 513 Orlando, FL 32804 (407) 894-1280 APPOINTMENT TIME: (Please be at the office 30 minutes before) Welcome to NAFISA TEJPAR, M.D. PA. We appreciate
More informationLast Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Last Name First Name Middle Initial Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Home Phone ( ) Mobile
More informationAtlantis Physical Therapy Associates
Atlantis Physical Therapy Associates Date Called/Walk-In: Appointment Date: Time: PT/OT: Diagnosis/ICD9/Body Parts: Frequency & Duration: X Referring Doctor: Dr. Phone#: Fax: NPI: Addresss: Ins Type: (Circle
More informationWelcome! We look forward to serving YOU. If we can do anything to make your time with us more enjoyable, please let us know.
Welcome! We want to thank you for allowing us the opportunity to provide you with the highest level of quality rehabilitation services possible. We are committed to providing you with a comfortable, friendly
More informationCARSON PHYSICAL THERAPY, INC.
PATIENTS WITH WORKER'S COMPENSATION INSURANCE We are interested in providing you with the best and most effective care possible. In order to begin your Physical Therapy as soon as possible, we offer you
More informationWELCOME TO TRI-COUNTY EYE CLINIC
WELCOME TO TRI-COUNTY EYE CLINIC Thank you for choosing Tri-County Eye Clinic as the provider for your eye care. You have an appointment at one of the following two locations: 15122 Dedeaux Road, Gulfport,
More informationCity: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip:
Name: Mailing Address: First M.I. Last Today s Date: Physical Address: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: Employer: Occupation: Employer s Address: Work
More informationPATIENT 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:
More informationEZ REHAB SOLUTIONS: Patient Intake Information
EZ REHAB SOLUTIONS: Patient Intake Information PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: : / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S. #: - - Home
More informationPATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary.
PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. Today s : Are you here for an injury that is work-related? YES NO N/A Patient Name (First-Middle-Last)
More informationJ. Richard Lilly, M.D., A.B.F.P., & Associates, P.C.
J. Richard Lilly, M.D., A.B.F.P., & Associates, P.C. PATIENT REGISTRATION - Please PRINT Clearly Patient Name First Middle Last Date of Birth Age Home Address Apt. No. City State Zip code Occupation Social
More informationGrey Physical Therapy and Sports Medicine Center
Grey Physical Therapy and Sports Medicine Center 101 Phoenix Ave, 2D Body Made Better by Grey A Tradition of Caring Since 1984 Enfield, CT 06082 Ph (860) 741-2541 F (860) 745-5264 Patient Information First
More informationWelcome to Avida PT. The purpose of this letter is to provide you with some helpful information to prepare you for your visits to our facility.
AVIDAPT 1391 Dublin Rd, Columbus, OH 43215 614-487-9715 avidapt.com Welcome to Avida PT. The purpose of this letter is to provide you with some helpful information to prepare you for your visits to our
More informationOffice Policies Dear Patient: We would like to take the opportunity to explain the policies of our office. Please take notice of the following:
Office Policies Dear Patient: We would like to take the opportunity to explain the policies of our office. Please take notice of the following: Please contact our answering service after hours for EMERGENCY
More informationPERSONAL INFORMATION
Date: Bruns Chiropractic Clinic EXISTING PATIENT INTAKE FORM (For patients treated within the past 3 years) PERSONAL INFORMATION Name: First MI Last Preferred Name: Gender: M F DOB: / / Age Social Security
More informationPraxis 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
More informationFunction First Physical Therapy, P.C. Patient Intake Form
Patient Intake Form Patient Information: Last Name: First Name: Sex: Date of Birth: SS#: - - Address: City: State: Zip Code: Work#: ( ) - Home#: ( ) - Email: Mobile#: ( ) - Marital Status: Single Married
More informationLast Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Last Name First Name Middle Initial Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Home Phone ( ) Mobile
More informationBOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES
BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES Patient Name: Date: FINANCIAL POLICY FOR PATIENTS Effective July 10, 2000 our office has established
More informationHORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME
HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME We are pleased you have chosen us for your physical therapy needs. Our office is committed to providing
More information