THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS!

Transcription

1 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 by your insurance carrier (including your insurance card) to your first appointment. If you have any questions regarding the completion of these forms, please do not hesitate to contact our office. As a consideration to other patients waiting for services, please provide adequate notice in the event of a necessary cancellation. We look forward to seeing you soon! **For your comfort, please bring shorts if you have a back or leg problem. Quality Physical Therapy 908 Hanover Street Manchester, NH Clinic (603) Fax (603)

2 QUALITY PHYSICAL THERAPY 908 HANOVER STREET, MANCHESTER, NH (603) PATIENT INFORMATION PATIENT NAME: (Please Print) HOME PHONE: ADDRESS: CITY: ZIP AGE: BIRTHDATE: SEX: MARITAL STATUS: SS# ADDRESS (for newsletter) EMPLOYERS NAME WORK PHONE EMPLOYERS ADDRESS PRIMARY CARE PHYSICIAN: REFERRING PHYSICIAN: SPOUSE (OR PARENT IF MINOR): HOME PHONE (if different) ADDRESS (if different) EMPLOYERS NAME: WORK PHONE: EMPLOYERS ADDRESS: PRIVATE INSURANCE OR MEDICARE INFORMATION NAME OF INSURANCE COMPANY NAME OF INSURED INSURANCE TEL# INSURANCE COMPANY ADDRESS: INSURANCE IDENTIFICATION # GROUP # SECONDARY INSURANCE COMPANY NAME OF INSURED INSURANCE TEL# INSURANCE COMPANY ADDRESS: INSURANCE IDENTIFICATION# GROUP# COMPLETE THIS SECION IF WORKERS COMPENSATION INSURANCE CARRIER INSURANCE TEL# ADDRESS CONTACT PERSON DATE OF INJURY CLAIM# EMPLOYER WHEN INJURY OCCURRED WORK PHONE EMPLOYER ADDRESS COMPLETE THIS SECTION IF AUTO ACCIDENT OR PERSONAL INJURY NAME OF YOUR AUTO INSURANCE NAME OF INSURED INSURANCE TEL# INSURANCE ADDRESS DATE OF INJURY CLAIM # NAME OF THIRD PARTY INSURANCE COMPANY NAME OF INSURED INSURANCE TEL# COMPLETE THIS SECTION IF LEGAL CASE LAW FIRM NAME OF ATTORNEY ADDRESS ATTORNEY TEL# OFFICE USE ONLY DATE OF EVAL THERAPIST DIAGNOSIS #1 #2

3 Quality Physical Therapy 908 Hanover Street, Manchester, NH How did you hear about QPT? Friend M.D. Newspaper Other MEDICAL INFORMATION QUESTIONAIRE IN ORDER TO EVALUATE YOUR CONDITION FULLY, THE FOLLOWING PATIENT HISTORY IS ESSENTIAL. PLEASE BE AS ACCURATE AS POSSIBLE. PLEASE FEEL FREE TO CONFIDENTIALLY DISCUSS ANY QUESTIONS WITH YOUR THERAPIST. THANK YOU. PRESENT ILLNESS OR INJURY: For what condition or symptoms are we seeing you? When did this problem begin? (Date) - - What treatment have you already received? Where have you received Physical Therapy treatment for this injury? Has this problem occurred in the past? Yes No If yes, when? (Date) - - Have you had any fever within the last week? Yes No PAST MEDICAL HISTORY: (Please indicate if you have had any of the following conditions.) Heart Disease or Heart Attack High Blood Pressure (Hypertension) Stroke Epilepsy or Convulsions Kidney/Bladder Problems Diabetes Tumor/Cancer Emphysema Asthma/Chronic Bronchitis Tuberculosis Hepatitis Ulcers Yes No Yes No Bleeding or Blood Disorders Hernia Thyroid Disease Venereal Disease Genital or Gynecological Disorders Congenital Abnormalities Arthritis Osteoporosis Are you now pregnant? Do you have a pacemaker? Do you have any surgical implants? Alcoholism/Drug Abuse Other medical problems not listed: Surgery: (List al previous operations and indicate approximate dates.) Fractures and other serious injuries: (List type and approximate date.) Allergies: Yes No Please list: Smoking: Yes No Medications: (Please list all present medications) Latest Physical Exam: Name of Family Doctor: Current Weight: Height: FAMILY HISTORY: Has any immediate (blood) relatives had any of the following: Cancer Heart Disease Arthritis Yes No Yes No Bleeding Tendency Diabetes Stroke IN CASE OF EMERGENCY, PERSON TO BE NOTIFIED: NAME: (Please Print) Relationship: Employer s Address (if applicable) Telephone: (work) (home) Signature: Date:

4 To Our Patients Regarding Cancellation and No-Shows The following are our policies regarding cancellations and no-shows. We take this subject seriously at the clinic because it can make the difference between whether you succeed in your treatment or not. Usually your referring doctor and /or your therapist has prescribed a set frequency of treatment. Showing up as scheduled for these visits is your most important job. Other than that, all you need to do is follow your therapist s instructions and we will be able to help you achieve your goals in treatment. We require 24 hours notice in the event of a cancellation. It is your responsibility when you call in to have an alternative time in mind that will ensure you get in the full prescribed number of treatments that week whenever possible. (In some cases, this may not be possible since some forms of treatment are not recommended two sequential days.) There is a $25 charge for a cancellation without proper notice. This charge will not be covered by insurance and will have to be paid by you personally. If you are a Worker s Compensation and Personal Injury patient, documentation of any missed appointments is forwarded to your Case Manager and Primary Physician and this could jeopardize your claim. You may need to see a therapist other than the one who normally treats you if you rearrange your appointment. All of our therapists are experienced professionals and they will study your patient chart so you will be in good hands. You will return to your original therapist on the next regularly scheduled visit. Please understand that your pain will probably increase and decrease as your course of treatment progresses and before it is finally erased. Either condition can seem to be a reason not to come for treatment: a) if you are feeling worse and think the treatment is not working or, b) you are feeling better and it is a great day for wind-surfing. Neither of these conditions are legitimate reasons not to come in: a) if you are in pain, come in and get it fixed, b) if you are not in pain, now is the time that we can begin doing some real correction of the underlying causes of your problem, educate you so you will not re-injure yourself etc. When you do not show as scheduled, three people are affected: You because you don t receive the treatment you need as prescribed by the doctor and/or physical therapist; The therapist who now has a space in their schedule since the time was reserved for you personally; Another patient who could have been scheduled for treatment if you had given proper notice. Please co-operate with us in this regard. We are looking forward to working with you. Patient Signature Date Interviewer Signature Date

5 Quality Physical Therapy NOTICE OF PRIVACY PRACTICES Effective April 14, 2003 the Federal Government requires us to notify you of our privacy practices. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY. Our commitment here at Quality Physical Therapy is to serve our clients with professionalism and caring, being sure at all times to protect the privacy and security of all protected health information. During the course of serving your interests in may become necessary to share information with other health care providers or business associates. The following are examples of instances where information may be shared: During treatment, we may find it necessary to acquire an x-ray or MRI report. For payment purposes, we may use the services of a billing service. During treatment, we may need a second opinion. We here at Quality Physical Therapy are committed to obeying all federal, state and local laws and regulations regarding privacy practices. If any other uses or disclosures than the ones listed above are needed. Information will only be released with the prior written authorization of the individual in question. This written authorization may be revoked at anytime by the individual as provided by law. If you have any questions or comments regarding your Protected Health Information, feel free to contact our Compliance Officer, Dana Kennedy at (603) I have read and understand the above Notice of Privacy Practices. Signed Date (Patient or Legal Guardian)

6 RELEASE OF INFORMATION I hereby authorize Quality Physical Therapy to disclose or obtain all or any part of my or my dependent s records to or from any person or corporation which may be liable for all or part of the charges of Quality Physical Therapy including, but not limited to insurance companies, worker s compensation carriers or employers. ASSIGNMENT OF BENEFITS I, hereby assign all medical benefits, to include major medical benefits to which I am entitled, including Medicare and other health plans to Quality Physical Therapy. I understand that I am financially responsible for all other charges whether or not they are paid by said insurance. I hereby authorize Quality Physical Therapy to release all information necessary to secure payments of said benefits. MY FINANCIAL RESPONSIBILITY I understand that I am responsible for all services rendered by Quality Physical Therapy. Once you receive your statement, you are required to pay your balance in full within twenty (20) days. Payment arrangements can be made if necessary. In the event it becomes necessary to place your account in collections a thirty-five percent (35%) fee will be added to your outstanding balance. LEGAL COST I understand that should Quality Physical Therapy be required to take legal action to recover payments for services rendered, I am responsible for all legal costs. CANCELLATIONS I am required to give a twenty-four (24) hour notice of any cancellation. I understand that Quality Physical Therapy may be required to notify my insurance carrier of all cancelled or broken appointments and a charge may be assessed. I hereby give my consent for services at Quality Physical Therapy. Signed: Date: Note: Any alterations to this form must be initialed by both parties.