If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment.

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1 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 Therapy take very seriously. Your commitment to your physical therapy program is critical to your success. We will recommend treatment and set goals for you. In order to reach those goals you must do your part and your most important part is to make each and every appointment. We will schedule and provide you with your appointment times to keep track of as well as give you a reminder when you check out. If you misplace your appointment times please give us a call to review your appointment dates. While we expect you to keep all your appointments, we recognize there may be a time when you need to cancel. We would appreciate 24-hour notice if you need to cancel so we can fill your appointment time. If you do not give 24 hour notice or no show for an appointment, a $30 fee may be billed to you. Our number is Ext. 93. If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment. Our staff will provide you with as much information regarding your insurance coverage as possible. We will contact your insurance company to verify your physical/occupational therapy benefits and let you know what your responsibility will be and due at time of service. We encourage you to call your insurance carrier to discuss your coverage and what your financial obligations may be as we sometimes are given wrong information. Please speak with our Front Desk Specialist if you have any questions regarding your appointments, insurance, financial responsibilities or any other issues. Please speak with your therapist if you have any questions regarding your therapy treatment. We thank you for choosing POST Physical Therapy Brookline and we look forward to working with you and helping you reach your goals. -The Staff at POST PT I have read and understand this policy: Patient/Guardian Print Name

2 POST Physical Therapy Registration Form Demographic Information Name First MI Last Address Street PO Box Apt # Address City State Zip Preferred Phone Secondary Phone Preferred Reminder (circle): Phone Gender: M F Marital Status: M S D DOB: How did you hear about us? Have you had Physical Therapy before? YES NO Physician Information Primary Care Physician Name Referring Physician Name Phone - - NPI# NPI# Fax - - Primary Health Insurance Information Insurance Company: Member ID: Group#: Subscriber: of Birth: Relationship to Patient: Phone: Address: Secondary Health Insurance Information Insurance Company: Member ID: Group#: Subscriber: of Birth: Relationship to Patient: Phone: Address:

3 1. CHIEF COMPLAINT/AILMENT/INJURY: 2. DATE OF INJURY: DATE OF SURGERY: 3. BRIEFLY DESCRIBE HOW YOU WERE INJURED: 4. DID YOU RECEIVE PHYSICAL THERAPY FOR THIS? YES NO IF SO, WHEN WHERE HOW MANY VISITS? 5. HAS YOUR CONDITION BEEN GETTING: WORSE SAME BETTER 6. WHAT ARE YOUR CURRENT MEDICATIONS? * Please list them 7. MARK THE NUMBER THAT BEST CORRESPONDS TO YOUR PAIN: BEST WORST BEST WORST 8. WHAT DECREASES/MAKES YOUR CONDITION BETTER? (MARK ALL THAT APPLY) 9. WHAT INCREASES/MAKES YOUR CONDITION WORSE? 10. PREVIOUS MEDICAL INTERVENTION X-RAY MRI CATSCAN INJECTIONS 11. WHAT ARE YOUR GOALS TO BE ACHIEVED BY THE END OF THERAPY?

4 ASSIGNMENT / INSTRUCTION FOR DIRECT PAYMENT TO HEALTH PROVIDER I hereby instruct the above named insurance company/companies to pay by check made out to and mailed directly to: POST Physical Therapy Brookline for professional or medical expenses allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee and I have agreed to pay, in a current manner, any balance of said professional fees for non-covered services and/or fees, over and above the insurance payment or as required by my insurance policy. I understand that POST Physical Therapy complies with HIPPA and will protect my Protected Health Information (PHI) and will use it as allowable by law in the treatment, billing and collection pertaining to my care until my case is closed and full payment is received. I also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney for the purpose of securing payment under this policy of insurance or to any Medical Provider associated with my case to effectively treat me. The authorization is in effect until 90 days from the date the last bill is collected. HIPPA REGULATIONS A photocopy of this Assignment shall be considered effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney for the purpose of securing payment under this policy of insurance under the HIPPA guidelines. Patient Name (Printed) Patient Signature Parent or Guardian (Printed) Relationship Parent or Guardian Signature Witness CONSENT TO TREATMENT AND DISCLOSURE OF PATIENT INFORMATION I hereby authorize the professional staff at POST Physical Therapy Brookline to examine and treat me with physical therapy for the injury I have been referred here for or referred myself to. I also authorize my protected health information to be disclosed to my insurance company (s), my doctor and /or other healthcare providers as well as my attorney. Patient Signature Patient Printed Name Staff Witness Signature Parent or Guardian Signature (if under 18)

5 Patient s Financial Responsibility Welcome to POST Physical Therapy Brookline! To help you better understand your physical therapy benefits, we have contacted your health insurance company to get this information. We strongly suggest that you contact them as well to verify the benefit information that we have obtained. If any contradictory information is given, we will work with you to get the correct information. However, we assume no liability for any misunderstanding or errors made by your insurance carrier in regards to the information we receive and what your ultimate responsibility is for your visits. We will bill your health insurance carrier for services rendered as a courtesy to you and ask that you pay promptly for any balance due after the insurance has paid. We expect payment for co-pays at the time of service. Payment plans for co-insurance, deductibles, etc. can be made at the time of service. Many health insurance carriers require a referral or authorization in order to receive physical therapy treatment. Please note what your specific plan requires and work together with our office to make sure the appropriate information is in place before we have scheduled you for more visits. If you are seen without a referral or authorization, you may be charged for the visits. We will work with you to keep you informed of when a referral is needed. Based on the information we received, your responsibility is as follows: Primary Insurance Co-pay: Co-Insurance: * Allowed Visits per year: Referral Required: Deductible: * *These amounts are estimates and while you are not required to pay your deductible or co-insurance at time of service, if you would like to do so to alleviate a building balance, we will be happy to work out a payment plan with you. The above financial information has been read and explained to me. I understand my financial responsibility. Patient/Guardian