Physical Therapy Rehabilitation, L.L.C.

Transcription

1 & Physical Therapy Rehabilitation, L.L.C. Patient Information Name: (First name) (Last name) (Middle initial) Address: (City) (State) (Zip code) Home#: Cell#: Work#: Social Security#: _ Date of Birth: -.:1 -.:1 Place of Employment: Occupation: Please Circle: Male or Female Please Circle: Single Married Legally separated Divorced Widowed Emergency Contact: Phone#: Relationship to Patient: Address: How did you hear about us? How would you like to receive information from us? (Circle one) text call Insurance Info. Name ofinsurance: Name ofinsured: Relationship to patient: Social security # of Insured: Date of Birth of Insured: History Are you currently having or recently received home health? Circle one: Yes or No Have you had physical therapy this calendar year? Circle one: Yes or No Date of onset: ---'1 ---'1 Is injury related to an auto accident? Referring Physician: Date oflast Dr. appt.:

2 Patient: Past Medical History DOB: Please indicate whether you have had any of the following conditions: Hea rt Disease 0 r A tta ck Yes N0 R h e u mat i c Fever Y es N0 High B I 0 0 d Pressu r e Y es N0 5 tro ke Y es N0 Epi lepsy or Convu Ision Yes N0 D i abe t e Yes N0 Tu mor 0 r Ca n cer Y e s N Resp ira tory D i se ase Ye s N0 P n eu m oni a or Em physem a Yes N0 Tu be rc u I os i Yes N0 Ast h m a Yes N0 Hepat i tis Yes N0 P ept i cuice r or Pan c rea titi Yes N0 Anemia or other Blood Disorders Yes No Bleed i ng D iso rd ers Y es N0 Her n i a Y e s N ThYr0 i d 0 i5e a 5e Yes N0 Ve n era I D i sea se Yes N Conge nita I Ab norm a lities Y es N0 Are yo u Pregn ant Yes N0 Do you have a Pacemaker Yes No Do you have any Su rgica I Imp la nts Yes N0 Are you a 5m0 ke r Yes No Allergies Please include ALL Allergies: Penicillin or other Antibiotics Yes No Morphine, Codeine, or other Narcotics Yes No N ovoca i n e, or other I oca I An es th etics Yes No PI ease list oth er Su b sta n ces Family History Ca nce r Yes No Hea rt Dis ea 5e Yes No Art h ri t is Yes No Tub ercu los i Yes No High Blood P ressu re Yes N0 BI eed i ng Ten den cy Yes N0 D i a b etes Yes N0 5t r 0 ke Ye 5 N0 Gout Ye 5 No List Previous Surgeries: List Current Medications:

3 nee Physical Therapy & Rehabilitation, L.L.C. 508 North Acadia Rd. Ph. (985) Thibodaux, Louisiana Fax ( NOTICE OF PATIENT INFORMATION PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INfORMATION ABOUT YOU MA Y BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMAnON. PLEASE REVIEW IT CAREFULLY. ADVANCE PHYSICAL THERAPY & REHABILITATION, L.L.c. LEGAL DUTY Advance Physical Therapy & Rehabilitation, L.L.c. is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described herein. USES AND DISCLOSURES OF HEALTH INFORMATION Advance Physical Therapy & Rehabilitation, L.L.c. uses your personal health information primarily for treatment (for example, to contact you to provide appointment reminders via phone, or to provide you with information about treatment alternatives or other health related benefits that may be of interest to you); obtaining payment for treatment (for example, sending copies of your notes to your insurance company to substantiate our claims); conducting internal administrative activities and evaluating the quality of care that we provide (for example, performing monthly quality assurance for Corporate Compliance to ensure that we are following the applicable Federal and State laws). Advance Physical Therapy & Rehabilitation, L.L.c. may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, and emergencies. We also provide information when required by law. In any other situation, Advance Physical Therapy & Rehabilitation, L.L.c. policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time. Advance Physical Therapy & Rehabilitation, L.L.c. will at all times do our very best to protect your personal health information but there may be instances during which your personal health information may be incidentally disclosed during the normal course of business. Some examples would include but are not limited to: conversations may inadvertently be overheard in our waiting area, our reception area, our billing area, our "gym" area (where there are often multiple patients using this area), or emanating from a private treatment room. When messages are being played back from our answering machine, someone in the reception area may be able to hear the messages. When filling out your paperwork it is possible that someone sitting next to you may be able to view your paperwork as you write. When verifying insurance benefits someone sitting in the waiting room or passing down the hall may overhear the phone conversation. Someone passing by may be able to transiently see your chart as a therapist is documenting in it or if copies of notes are being made for operational or payment purposes. When leaving a phone

4 message for you we will only leave the minimum amount of information necessary for you in case the message could be overheard by someone else. Our appointment schedule will not be visible when not in use by unauthorized personnel but someone may be able to briefly view the schedule when it is being used by authorized personnel. Our fax machine is located in our front office which is normally not accessible to our clients but if a client is discussing a billing issue with our office staff they may be able to glance at a fax in our machine or at billing information in the billing office that is in current use. Advance Physical Therapy & Rehabilitation, L.L.C. may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room, patient exam areas, and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time. PATIENT'S INDIVIDUAL RIGHTS You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records, but we do not necessarily need to agree to these requests. You have the right to receive confidential information by alternative means or at an alternative address if you provide us with your request in writing. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes. You may also request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. Advance Physical Therapy & Rehabilitation, L.L.c. will consider all such requests on a case by case basis, but the practice is not legally required to accept them. COMPLAINTS If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to: Privacy Officer Advance Physical Therapy and Rehabilitation, L.L.c. 508 North Acadia Road Thibodaux, LA If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint. CONT ACT PERSON The name and address of the person you can contact for further information concerning privacy practices is: Privacy Officer Advance Physical Therapy and Rehabilitation, L.L.C. 508 North Acadia Road Thibodaux, LA (985)

5 HIPAA Privacy Policy By signing below, I hereby acknowledge receipt of this privacy notice and that I have read and understand the terms and conditions outlined herein. Patient/Legal Guardian Signature: Date: Medical Records Authorization I hereby authorize direct payment to be sent to Advance Physical Therapy & Rehabilitation, LLC for Physical Therapy benefits if any, otherwise payable to me under terms of my insurance. I hereby authorize Advance Physical Therapy & Rehabilitation, LLC to release any information acquired in the course of my examination or treatment. I hereby authorize any physician, hospital, or medical facility to provide all information on my medical history and treatment to Advance Physical Therapy & Rehabilitation, LLC. I authorize photocopies of this form to be as valid as the original. ** In addition to the doctor and insurance company on file I hereby authorize Advance Physical Therapy & Rehabilitation, LLC to release any information about me to: Patient/Legal Guardian Signature: Date: Consent for Treatment I acknowledge and understand that, in presenting myself for treatment at Advance Physical Therapy & Rehabilitation, LLC, that I authorize and consent to the administration and performance of physical therapy which may be provided by physical therapists and/or any other members of the Advance Physical Therapy & Rehabilitation, LLC staff. Minors must have parent or legal guardian sign the consent form. Patient/Legal Guardian Signature: Date:

6 Physical Therapy Pre-Exam Questionnaire In order to evaluate your condition fully, please be as accurate as possible. Thank you. Patient Name: DOB : Date: 1. What is your age? What is your gender? Male / Female 3. What is your occupation? Are you working now? Yes / No 4. Have you had physical therapy before? Yes / No 5. Where is your pain/problem? What caused your pain/or problem? Approximately when did it start? Is it getting better, worse, or staying the same? Have you ever had this pain/problem before? Yes / No 10. Is your pain constant (never goes away)? Yes / No 11. On the scale below, Circle your worst pain level in the past couple of days: Mild Moderate Severe Are you taking any medication for this pain/problem? Yes / No -If yes, what and does it help? 13. Are any of your usual everyday activities affected? Yes / No -If yes, describes how. 14. List all medical conditions you have (or were told you have)?