PHYSICAL THERAPY ENROLLMENT FORMS

PHYSICAL THERAPY ENROLLMENT FORMS Name: of Birth: / / First Middle Last m d y Address: Street Address City State Zip Home Phone #: Email: Work Phone #: Employer: Marital Status: Student: Check here if you do not you wish to be placed on the H &D Physical Therapy mailing list. In case of emergency, who should we call? Name: Phone #: How did you hear about H &D Physical Therapy? Have you been before? If so, when? Is it the same problem? Purpose of your Visit (Problem): Do you have a prescription? Referring Physician: Phone #: Post Operation? Surgery : Have you had physical therapy this year? If so, how many visits were used? Is this injury a work related or auto related accident? INSURED S INFORMATION Check here if insurance card already supplied to office Name of Insured: of Birth: / / m d y Phone #: Relationship to insured: Insurance Carrier: Member ID: Group #: Group Name: WORKMAN S COMPENSATION/MOTOR VEHICLE INSURANCE (COMPLETE IF WORK OR AUTO RELATED): ONLY IN-NETWORK of Accident: Policy/Claim ID: Auth/Precert #: Carrier Name: Address: Phone: Street Address City State Zip Claims Adjuster/Contact Person s Name: Phone: 1

INFORMED CONSENT FOR PHYSICAL AND/OR OCCUPATIONAL THERAPY Please read, initial and sign below: Physical & Occupational Therapy involves the use of many different types of physical evaluation and treatment. At H&D Physical & Occupational Therapy and H&D Dynamic Therapy, we use a variety of procedures and modalities to help us to try and improve your function. As with all forms of medical treatment, there are benefits and risks involved with physical & occupational therapy. Since the physical response to a specific treatment can vary widely from person to person, it is not always possible to accurately predict your response to a certain therapy modality or procedure. We are not able to guarantee precisely what your reaction to a particular treatment might be, nor can we guarantee that our treatment will help the condition you are seeking treatment for. There is also a risk that your treatment may cause pain or injury, or may aggravate previously existing conditions. You have the right to ask your physical or occupational therapist what type of treatment he or she is planning based on your history, diagnosis, symptoms and testing results. You may also discuss with your therapist what the potential risks and benefits of a specific treatment might be. You have the right to decline any portion of your treatment at any time before or during your treatment session. Therapeutic exercises are an integral part of most physical & occupational therapy treatment plans. Exercise has inherent physical risks associated with it. If you have any questions regarding the type of exercise you are performing and any specific risks associated with your exercises, your therapist will be glad to answer them. I acknowledge that my treatment program has been explained by H&D Physical & Occupational Therapy and H&D Dynamic Therapy. I also acknowledge all of my questions have been answered to my satisfaction. I understand the risks associated with a program of Physical & Occupational Therapy as outlined to me, and I wish to proceed. I authorize my insurance company to pay medical benefits directly to H & D Physical Therapy. I authorize the release of any requested information to my insurance company which may be necessary for evaluating claims. I agree to be responsible for the balances of payment that is NOT covered by insurance, the interest accrued for outstanding balances, and any late cancellations or no show fees. I have reviewed and received a copy of the tice of Privacy Practices for H & D Physical Therapy (Form POPT 1000) and give my permission to H & D Physical Therapy to use and disclose my health information in accordance with it. I agree to that if I must cancel an AM appointment, I will do so by 5pm the night before the scheduled visit. If I must cancel a PM appointment, I will do so by 10am on the day of the visit. I understand a failure to cancel on time (as stated above) or failure to show up for a scheduled appointment will result in a charge of $75, billed to me, not my insurance carrier. I understand lockers are available for my use at my own risk. H & D Physical Therapy shall not be liable for the disappearance, loss, theft of, or damage to my personal property. I have been informed of the possibility that physical therapy treatment may not be covered by my health care insurer without the referral of a physician, but may be a covered expense, if treatment was rendered pursuant to such referral. Waiver/Release: I understand that Plus One, my employer and the building owner are not affiliated with H & D Physical therapy and neither is anyway responsible for the physical therapy provided by H &D Physical Therapy. I hereby authorize & request H & D Physical Therapy to provide such medical care & administer procedures and treatments as in the judgment of the physical therapists in attendance & deemed necessary & advisable Patient 2

PATIENT FINANCIAL AND INSURANCE AGREEMENT H & D Physical & Occupational Therapy/H&D Dynamic Therapy is committed to providing you with the best possible care. If you have health insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our payment policy. Payment for non-covered services is due at the time services are rendered unless payment arrangements have been approved in advance by our staff. We accept cash, checks, MasterCard, Visa and American Express. We will process and submit your insurance claim form for your reimbursement. Returned checks and balances older than 30 days may be subject to additional collection fees and interest charges of 1 ½% per month. We will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize, however, that: 1. Your insurance is a contract between you, your employer and the insurance company. H & D Physical Therapy is not a party to that contract. 2. Our fees are generally considered to fall within the acceptable, usual, customary, and reasonable range by most companies, and therefore are covered up to the maximum allowable amount determined by each carrier. 3. t all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain services they will not cover. We must emphasize that, as physical therapy providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. I acknowledge I have read and understood the above financial agreement. If your primary health insurance is either BLUE CROSS/BLUE SHIELD or OXFORD, your health insurance carrier may not reimburse H&D directly for your physical or occupational therapy treatments. Instead, BLUE CROSS/BLUE SHIELD or OXFORD, mail the payments for these services directly to you. You may either endorse these checks over to H&D Physical & Occupational Therapy or we can bill your credit card for these treatments. Please choose your preference: I agree to endorse any payments for H&D physical or occupational therapy treatments that I receive from my insurance carrier as well as a copy of the explanation of benefits to the front desk. I authorize H&D Physical & Occupational Therapy or H&D Dynamic Therapy to charge my credit card (information below) for physical or occupational therapy services rendered. Credit Card Authorization I, hereby authorize H&D Physical & Occupational Therapy or H&D Dynamic Therapy to charge my credit card for co-payments/co-insurance and for any unpaid balances. Any remaining credit on my account after all insurance reimbursements have been received will be refunded. I understand this form will not be divulged to any person not engaged in the professional use or maintenance of said files and all information will be kept confidential as required by our federal privacy policies. Name as it appears on card: Visa/MC/AMEX Account # OFFICE USE ONLY: Deductible amount expected when services are rendered: $ Co-insurance/Co-Payment expected when services are rendered: $ Exp. : 3

PATIENT HISTORY PRESENT STATUS What is your chief complaint? Rate your chief complaint in order of severity from 0 to 10, 0 being the least and 10 being the most severe: Pain Loss of motion Swelling Stiffness Loss of function When did the problem begin? (specify date if applicable): How did the problem begin? Where is the problem? Indicate where your symptoms are on the diagram to the left, with the symbol indicating the type of pain or symptoms you are having: + = Numbness/tingling # = Pain <> = Other Circle a number from 0-10 to indicate the severity of your pain no pain = 0 1 2 3 4 5 6 7 8 9 10 = unbearable pain What in particular makes your pain or symptoms worse? What, if anything, eases your pain or symptoms? Has this problem affected your daily life (job, exercise etc.)? Are your symptoms: Improving Stable Worse Have you had previous similar occurrences of these symptoms? If yes, describe: What, if any, treatment have you had for this problem? Physical therapy Chiropractic Acupuncture Other Did this treatment help? Explain: Are your symptoms: Improving Stable Worse Have you had any special tests (MRI, x-rays, etc) and what were the results? MEDICAL HISTORY Have you been discharged from a hospital or skilled nursing facility in the last 30 days? If yes, date of discharge: List any past surgeries you have had: List all medications you are presently taking: Are you pregnant? If yes, how many months? Have you experience or are you currently experiencing? Allergies Anemia Angina or Chest Pain Arthritis or pain in a joint Asthma Cancer Chronic Bronchitis CirculatoryProblems Depression Diabetes Difficulty Walking Difficulty Swallowing Emphysema Fracture Headaches Heart Disease Hepatitis High Blood Pressure Kidney Disease Low Back Pain Neck Pain Obesity Open Skin Sores Osteoporosis Pacemaker Pain with coughing or sneezing Pneumonia Rheumatoid Arthritis Shortness of Breath Stomach Problems Stroke Weight change Urinary Tract Infection Mental Disorders Vestibular (Inner Ear) 4

DOCUMENTATION AND VERIFICATION OF MEDICATION MEDICATIONS (PRESCRIPTION AND OVER THE COUNTER), SUPPLEMENTS, VITAMINS; AT INITIAL Medication Name Dose (mg) Quantity/Frequency Initial/ if same at re-evaluation Initial/ if same at re-evaluation CHANGES AT RE-EVALUATION Medication Name Dose (mg) Quantity/Frequency /Patient Initials Initial/ if same at re-evaluation 5

NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS (NEMB) There are items and services for which Medicare will not pay. Medicare does not pay for all of your health care costs. Medicare only pays for covered benefits. Some items and services are not Medicare benefits and Medicare will not pay for them. When you receive an item or service that is not a Medicare benefit, you are responsible to pay for it, personally or through any other insurance that you may have. The purpose of this notice is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you will have to pay for them yourself. Before you make a decision, you should read this entire notice carefully. Ask us to explain, if you don t understand why Medicare won t pay. Ask us how much these items or services will cost you ($185.00 per session) Medicare will not pay for: Physical Therapy services, because of financial limitations (cap) beyond the annual of $1880.00 (allowed charges) per beneficiary. 1. Because it does not meet the definition of any Medicare benefit. 2. Because of the following exclusion * from Medicare benefits: *Personal comfort items. *Routine physicals and most tests for screening. *Most shots (vaccinations). *Routine eye care, eyeglasses and examinations. *Hearing aids and hearing examinations *Cosmetic surgery. *Most outpatient prescription drugs. *Dental care and dentures (in most cases). *Orthopedic shoes and foot supports (orthotics). *Routine foot care and flat foot care. *Health care received outside of the USA. *Services by immediate relatives. *Services required as a result of war. *Services under a physician s private contract. *Services paid for by a governmental entity that is not Medicare. *Services for which the patient has no legal obligation to pay. *Home health services furnished under a plan of care, if the agency does not submit the claim. *Items and services excluded under the Assisted Suicide Funding Restriction Act of 1997. *Items or services furnished in a competitive acquisition area by any entity that does not have a contract with the Department of Health and Human Services (except in a case of urgent need). *Physicians services performed by a physician assistant, midwife, psychologist, or nurse anesthetist, when furnished to an inpatient, unless they are furnished under arrangements by the hospital. *Items and services furnished to an individual who is a resident of a skilled nursing facility (a SNF) or of a part of a facility that includes a SNF, unless they are furnished under arrangements by the SNF. *Services of an assistant at surgery without prior approval from the peer review organization. *Outpatient occupational and physical therapy services furnished incident to a physician s services. * This is only a general summary of exclusions from Medicare benefits. It is not a legal document. The official Medicare program provisions are contained in relevant laws, regulations, and rulings. Patient Name: : : 6

MEDICARE SCREENING FORM A. Falls: Risk Assessment - For patients > 65 years of age; Eval or Re-Eval 1.Have you fallen in the last 12 months? 2.How many times have you fallen? If 2 or more, please complete a falls risk assessment. 3.Did your fall(s) result in injury? If yes, please complete a falls risk assessment. 4.Patient was not screened for falls secondary to: a.medical Reasons: e.g. patient is non-ambulatory. Specify medical reason: b.patient not Eligible e.g. language barrier. c.unspecified Reason: B. Falls: Plan of Care- For patients > 65 years of age; Eval or Re-Eval 1.Plan of Care includes consideration of appropriate assistive device and balance, strength and gait training. 2.Plan of care not documented for medical reasons. 3.Plan of Care not documented. Reason not otherwise specified. C. Pain Assessment Prior to Initiation of Patient Therapy and Follow-up - For patients > 18 years of age; Eval AND Re-eval 1.Pain was assessed on evaluation or on re-evaluation for intensity, quality and location AND a follow-up plan was documented. 2.Pain was assessed on evaluation or on re-evaluation for intensity, quality and location, but a follow-up plan was not documented, because patient was not eligible because of the absence of pain. 3.Pain was assessed on evaluation or on re-evaluation for intensity, quality and location, but a follow-up plan was not documented. Reason was not specified. 4.Pain assessment was not completed secondary to: e.g. compromised mental status, refuses. Reason: 5.Pain was not assessed for intensity, quality and location. Reason t Specified. D. Universal documentation of medications in the medical record - For patients > 18 years of age; Eval AND Re-Eval 1.Successfully reported on medical history questionnaire including all prescription, OTC medications and supplements and dosages and patient verification documented. 2.Successfully reported on medical history questionnaire including all prescription, OTC medications and supplements and dosages. Patient verification not documented, because patient is not eligible. 3.Patient is not eligible for medication assessment. 4.Medications & Supplements were documented without patient verification. 5.Medications & Supplements were not completely documented. E. Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up: For patients Age 65 and older BMI > or = 30 or <22, Age 18-64 BMI > or = 25 or < 18.5 at Eval or Re-eval. 1.BMI calculated and was normal, no follow-up plan needed or BMI calculated, was normal and follow-up plan documented. 2.Calculated BMI above the upper parameter and follow-up plan was documented. 3.Calculated BMI below the lower parameter and a follow-up plan was documented.. 4.Patient not eligible for BMI calculation for documented reasons. 5.BMI not performed and/or calculated BMI outside of normal parameters, follow-up plan not documented, reason not specified. Therapist : 7

POPT-1000 tice of Privacy Practices THIS NOTICE DESCRIBES HOW YOUR PERSONAL HEALTH RECORD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Protecting your privacy is of paramount importance to us, and we have implemented procedures to safeguard the information included in your files. Your Personal and Protected Health Information: We may gather personal and health information from you, other health care providers and third-party payers. This information is used for treatment, payment and health care operations. The following describes the ways we may use and disclose your Protected Health Information: We may provide PHI about you to health care providers, other practice personnel, or third parties who are involved in the provision, management or coordination of your treatment care. We may use or disclose your PHI so that we can collect or make payment for the health care services you receive or are going to receive. We may disclose your PHI to any third party you designate in writing. We may disclose your PHI if we believe it is necessary to prevent a serious threat to your health and safety or the health and safety of the public. We may disclose your PHI to a government agency if we believe you have been a victim of abuse, neglect or domestic violence. We will make this disclosure if it is necessary to prevent serious harm to you or other potential victims, you are unable to agree due to your incapacity, you agree to the disclosure, or required by law. We may disclose your PHI to a health oversight agency for activities authorized by law. We may disclose your PHI as required by a court or administrative order, or under certain circumstances in response to a subpoena, discovery request or other legal process. We may release your PHI as necessary to comply with laws relating to Workers Compensation or similar programs that are established by the law to provide benefits for work-related injuries or illness without regard to fault. Your PHI may be disclosed for military and veterans affairs, for national security and intelligence activities, or for correctional activities. We may use or disclose your PHI when required by law. We may use your name, address, phone number, e-mail, and your records to contact you with appointment reminder calls/emails, newsletters, postcards, greeting cards, information about physical therapy, Plus One Health and Wellness services, or other related information that may be of interest to you. Please note your rights regarding this information: 1.You are entitled to inspect and receive copies of your records upon written request. 2.You are entitled make a written request to amend your PHI files or put restrictions on certain uses and disclosure of PHI. 3.We accommodate any reasonable request, yet we retain the right to deny inclusion of amendments or use restrictions of your PHI. 4.You have a right to receive all notices in writing. 5.You have the right to request that we do not disclose your information to specific individuals, companies, or organizations. Any restrictions should be requested in writing. H &D Physical Therapy Duties We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice. Right to Revise Privacy Practices As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all pro tected health information we maintain. Contact Person For further information concerning our privacy practices or if you would like to submit a comment or complaint about our privacy prac tices, you can do so by sending a letter outlining your concerns to: Director of Physical Therapy H & D Physical Therapy 12 East 46th Street, NY, NY 10017 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 con cern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint. 8