PHYSICAL THERAPY BILLING POLICIES
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- Grace Underwood
- 8 years ago
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1 PHSICAL THERAP BILLIG POLICIES In order to maximize our ability to see and help heal all of our patients, we have set the following policies. Thank you very much for your compliance and understanding. LATE CACELLATIO POLIC We have a 24 hour cancellation policy. If you cancel within 24 hours before an appointment or if you do not show at all, you will be billed $60, payable before your next appointment can take place. If you are late for an appointment, you will be charged $20 per 15 minutes, up to 30 minutes. If you are later than 30 minutes for an appointment, the appointment will need to be rescheduled and a $60 charge will be applied. Please note that insurance will not pay for late fees. If you no show/late cancel two times in a row, we will no longer schedule you. CASH PAMET OR O ISURACE PATIETS For patients without insurance, or patients wishing to pay in full at time of service. We offer this service at a discounted rate. The ew Patient Evaluation is $130 and all following treatments at $97.50 a visit. We can also set up a payment plan if required. ISURACE An insurance policy is a contract between you and your insurance company. Payment for Physical Therapy is your responsibility. We do not accept responsibility for collecting an insurance claim or negotiating a disputed claim with your company. However, as a courtesy to you, we will assist you as follows: ALL ISURACE CLAIMS We require your insurance information prior to your first visit to verity your outpatient Physical Therapy benefits. Verification of benefits is OT a guarantee of payment by your insurance company. We strongly encourage you to call your insurance carrier directly so that you may better understand your responsibility, if any, for treatment costs. Upon receipt of your insurance information, our billing service will submit your claim to your primary and secondary insurance carriers. Payments will be made directly to us. our portion of the bill consists of (deductibles, co-payments, co-insurance, late cancel or no-show fees and any charges applied that are not met by your insurers). Payment is due within 10 days after receiving your statement. If you have questions please call us directly on for clarification. IDUSTRIAL ACCIDET (L&I) CLAIMS We require your claim number and employer information. For accepted claims, your bill will be paid in full by L&I or Self-Insured employers. If your claim is denied or rejected, contact our billing service immediately to make other arrangements, as you will be responsible for your bill. If you miss 2 appointments we are obligated to notify your claims manager, and we will no longer place you on our schedule. MOTOR VEHICLE ACCIDET CLAIMS Our service will bill the responsible insurance carrier based on the information you provide to us. Any unpaid balance is due within 10 days after you receive your statement. If the insurance carrier denies or excessively delays payment, you will be required to pay for treatment at time of service. METHODS OF PAMET We accept cash, personal checks, money orders, and all major credit cards. If you have questions about forms of payment, please ask our front desk. Checks returned for lack of funds will incur a $25 fee. ACCOUTS OVER 90 DAS OLD We will charge a Late Charge Fee of $30 for all accounts that are overdue by more than 90 days. This charge will be applied each month until the account is settled or payment plan agreed. Please call if your circumstances have changed and you may need to set up a payment plan to settle your account.
2 PERSOAL IFORMATIO The Pilates & Physical Therapy Center of Seattle, Inc FIRST AME LAST Ml BIRTHDATE AGE STREET SOCIAL SECURIT * CIT STATE ZIP DA PHOE EVEIG PHOE CELL PHOE Male Female Married/Partnered Single In case of emergency, please notify: AME RELATIOSHIP COTACT PHOE/S EMPLOMET IFORMATIO OCCUPATIO Full Time Part Time COMPA AME PHOE STREET CIT STATE ZIP STUDET? SCHOOL: IJUR IFORMATIO PRIMAR CARE PHSICIA PHOE DATE LAST SEE REFERRIG PHSICIA LOCATIO DATE LAST SEE DATE: OSET OF SMPTOMS PREVIOUS SURGERIES DATE LOCATIO PREVIOUS SURGERIES DATE LOCATIO MRI / CTSCA LOCATIO DATE PHOE X-RAS LOCATIO DATE PHOE ISURACE IFORMATIO PRIMAR ISURACE CO SUBSCRIBER RELATIOSHIP TO PATIET SECODAR ISURACE CO ID UMBER SUBSCRIBER RELATIOSHIP TO PATIET PHOE SIGATURE - PATIET (or Guardian) DATE: GUARDIA AME: HOW DID OU HEAR ABOUT US? Doctor Family Friend Street Signs Website Other:
3 FIACIAL POLICIES In order to maximize our ability to see and help heal all of our patients, we have set policies in place regarding late arrivals, cancels & financial matters, and it is very important that you understand these policies. RELEASE OF BEEFITS AD IFORMATIO / ASSIGMET OF ITEREST I authorize The Pilates and Physical Therapy Center or my insurance company to release any information required for this claim. I consent to receive treatment as prescribed by my doctor. A copy of this authorization shall be as valid as the original. SIGED: CACELLATIO / O SHOW POLIC I have read the Cancellation Policy and understand that if I do not appear for an appointment, or if I cancel within 24 hours of an appointment, I will be charged a $60 late cancellation fee, and I understand that this policy is rarely waived, even for illness and is strictly enforced. I also understand that late charges of $20 per 15 minutes will apply, and that my insurance does not cover late charges. Charges from a Late Arrival or o Show will be paid for on my next visit and before any further treatment can take place. ISURACE PAMET A claim will be submitted to my insurance company on my behalf. My portion of the bill is due within 30 days of invoice. In the event my insurance company denies payment, I am fully and directjy responsible for payment of my treatment All COPAS and LATE CHARGES are due at the Time of Service. Any care or medical supplies not covered by my insurance will require payment in full at the time of service. TERMS OF PAMET I am financially responsible for any balance due, within 30 days of invoice. I have read and understand the Pilates and Physical Therapy Center's Billing Policy. If, for any reason, my insurance company does not promptly remit payment, I understand The Pilates and Physical Therapy Center will not await payment but will require me to make payments on a current basis. The postponement by The Pilates and Physical Therapy Center of collections process on any unpaid fees shall not be considered a waiver of the right to collect the entire unpaid balance of fees owing. Returned check fee of $25 and a monthly late charge fee of $30 applied after 90 days. I have read fully and understand the terms and conditions laid out above in the CACELLATIO/O SHOW POLIC, ISURACE PAMET and TERMS OF PAMET policies. SIGED: Thank you very much for your compliance and understanding. We truly value your patronage and improving health.
4 ame: Date: PT: PRIVAC PRACTICES OTIFICATIO OF PRIVAC PRACTICES: Acknowledgement of Receipt We keep a record of the Physical Therapy services that we provide you. ou have a right to see, copy, and correct that record. We will not disclose your record to others unless directed to do so by you or an authorized legal authority. Please contact the Privacy Officer for more information. The otice of Privacy Practices, mandated by Federal law details your rights regarding your medical information. It requires your signature as an acknowledgment of receipt. Please Pick up our otice at the front desk when checking in for vour first appointment. I acknowledge that I have been provided with a copy of the otice of Privacy Practices. SIGED:, AUTHORIZATIO TO LEAVE PERSOAL HEALTH IFORMATIO Please check all that apply: Please leave my appointment reminder calls at phone # ou may leave a detailed message on voic at home # ou may leave a detailed message on voic at work # _ ou may leave a detailed message on my cell phone # ou may leave a detailed message with my spouse/ significant other/ family member: ame: Relationship: Phone: ame: Relationship: Phone: ame: Relationship: Phone: I understand that I am responsible for notifying the clinic if any of the the contact numbers change. SIGED: SIG-I DOCUMETATIO My name can appear on the appointment sign-in sheet. I prefer not to have my name on the appointment sign-in sheet, and agree to stop at the front desk each appointment to request a private sign-in sheet. SIGED:
5 Medical History Existing or Relevant Previous Conditions Allergies O es O o Dizzy Spells Oes O o MRSA O es O o Anemia O es O o Emphysema/Bronchitis Oes O o Multiple Sclerosis Oes O o Anxiety O es O o Fibromyalgia Oes O o Muscular Disease Qes O o Arthritis O es O o Fractures Oes O o Osteoporosis Oes O o Asthma Oes O o Gallbladder Problems Oes O o Parkinsons Oes O o Autoimmune Disorder o Oes O Headaches Oes Oo Rheumatoid Arthritis Oes Qo Cancer Oes O o Hearing Impairment O es O o Seizures Oes Oo Cardiac Conditions Oes O o Hepatitis Oes O o Smoking Oes O o Cardiac Pacemaker Oes O o High/Low blood pressure Oes O o Speech Problems Oes Oo Chemical Dependency Oes Oo High Cholesterol Oes O o Strokes Oes O o Circulation Problems Oes Oo HIV/AIDS Oes O o Thyroid Disease Oes O o Currently Pregnant O y es O o Incontinence Oes O o Tuberculosis Oes O o Depression Oes O n Kidney Problems Oes O o Vision Problems Qes O o Diabetes Qes O 0 Metal Implants Qes Q O Describe any other conditions If "es" to Any of the above, please explain and give approximate dates/describe any other Conditions Fall History D tj Injury as a result of a fall in the past year? Two or more falls in the last year? Surgical History Current Medications P Currently not taking any medications
6 ame: Date:. PT Initials:. Date: Onset of symptoms: Date: 1st seen physician: Have you had a prior injury to this area? Dates:_ Have you had previous therapy treatment for this? Describe: How did your symptoms begin? Indicate problem areas on the chart: For discomfort, use dark shading For tingling/numbness, use dotted shading tit* arrows to shov/ spreading! y U { i 1 ^ y / W Cv 1 rcj ess Rl V In the evening, do your symptoms change?. Increase _Decrease Is it difficult to get to sleep? Do your symptoms wake you up at night? Describe your symptoms in the morning: Describe your symptoms during the day: Do you have problems dressing, bathing, grooming? Is there anything you used to do that you are unable to do now? What makes your condition better? What makes your condition worse? What goals do you wish to achieve from physical therapy?_ Do you normally exercise regularly? What exercise? Do you own or have access to exercise equipment? What equipment?^ Would you be willing to participate in a home exercise program? Occupation: Are you working now? Full Time Part Time What positions are you in while you are working: Standing _Sirting Bending Lifting Walking Driving Other: Are any of these positions painful?_ What are your hobbies?
Orthopedic Initial Questionnaire. Date: Weight:
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Orthopedic Initial Questionnaire
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Body 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
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X Guarantor/Parent/Guardian Signature
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PATIENT 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
Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice?
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Thank you for choosing ALTITUDE PHYSICAL THERAPY, a Member of the P3 Network - PT-MD Kinect LLC & Partners in Health Healing Center
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Empower Physical Therapy
PAYMENT AND COLLECTION POLICY Payment is expected at the time of service. Unpaid balances left by your insurance companies will be your responsibility. In the event you are unable to pay the balance in
DEL 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 **********************************************************************************
Houston Healthcare Therapy Agreement
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Primary Policy Holder Same as Patient Relationship to Patient: Name: Address: Apt# City: Patient Information. Name: Address: Apt# City: State: Zip:
Patient Information Name: Address: Apt# City: State: Zip: Sex: MALE FEMALE of Birth: Cell Phone: Home Phone: Work Phone: Email Address: Employer: Employer Phone #: Employer Address: Social Security #:
Physical Therapy Services Medical History Form
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PATIENT INFORMATION (Please Print Clearly)
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Employment Status Full Time Part Time Retired Not Employed Work Address: City: State: Zip:
PATIENT INFORMATION First Name: Last Name: Middle Initial: Date: / / Address: City: State: Zip: Email: DOB: Male Female S.S. #: - - Home Phone: ( ) Mobile Phone: ( ) Work Phone: ( ) Employer: Occupation:
Dr. Ronnie Pollard, DPM 1563 Gilpin Street Denver, CO 80218 303-388-0976 www.elevationfoot.com
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Patient History Information
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General Dentistry Neuromuscular Dentistry Cosmetic Dentistry Sleep Medicine
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(928) 854-4307 MEDICAL HISTORY. Weight: _ Shoe size: _
2302 N. Stockton Hill Rd Ste. G 1731 Mesquite Ave Ste 4 1200 Mohave Rd MEDICAL HISTORY Weight: Shoe size: ~~~~~~~~~~~~~~~~~~~~~~~~~~PLEASECIRCLE: RIGHT or LE~ Is your problem due to an accident? YES or
Understanding the Billing Process. Our Mission. Cancellation/Change Policies
Our Mission At Core Conditioning we strive to enhance the overall health and quality of life for our clients. We want to help create a balanced lifestyle that will contribute to the individual s long-term
Dear Patient: Photo ID Insurance card(s) Prescription/referral for physical therapy Any Claim documentation (auto/w/c)
7500 Hanover Pkwy Ste. 103 Greenbelt, MD 20770 Phone: 301.446.1644 Fax: 301.446.1647 6510 Kenilworth Ave. Ste. 1100 Riverdale MD 20737 Phone: 240.770.8750 Fax: 240.770.8156 Dear Patient: Attached is your
Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone: ( )
Patient Information Date: First Name: Address: Surname: City: Postal Code: Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone:
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:
SOUTH COUNTY PHYSICAL THERAPY AND REHABILITATION CENTER, INC.
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Cancellation/No Show Policy
Cancellation/No Show Policy If you are unable to keep your scheduled appointment we require a 24 hour advance notice. Failure to provide this notice will result in a $50.00 cancellation/no show fee. You
Patient 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:
P.S. Please remember to bring your completed forms to your office visit!
Dear Patient: Please print the following forms and complete them as accurately as possible and bring them with you to your office visit. If you have any questions about the forms you can call my office
PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME MI
275 Collier Road NW, Suite 470 Atlanta, GA 30309 Tel: 404-351-1002 Fax: 404-350-8290 PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME
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San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet
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11120 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
PATIENT 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)