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 complete Patient Application. We have included a summary of each section to help you better understand what information is being requested. Please read, complete in its entirety, and bring this application with you to your appointment, along with: Photo ID Insurance card(s) Prescription/referral for physical therapy Any Claim documentation (auto/w/c) Section One This part if the application if for your personal demographic information. Legibly, in block letters, please enter all the requested information. Note: Enter your name as it is written on your health insurance card Guarantor name should be entered if the patient is a minor. Please enter your email address if you have one. This is used for contact purposes and for holiday/birthday cards etc.
Section Two This section refers to the reason you are coming to therapy. Note: Please enter the physician who referred you to physical therapy Emergency contact information Section Three Auto Accident or Workers Compensation If you have come to physical therapy because of an auto accident, a workers compensation (W/C) claim or you have an attorney assigned to your case, please complete this section. Section Four This section should be completed if there is an attorney assigned to your case. Section Five This section must be completed if you have health insurance. Even if you are using an auto claim or W/C claim, we MUST have your health insurance on record. Section Six All patients who either DO NOT have health insurance or wish to pay out-of-pocket for therapy treatment, must initial this section. Section Seven The purpose of section is to inform the therapist of your medical history. Please complete this section and include a separate list of medication you currently take, if applicable.
Section Eight. Financial Policy Statement. This section explains that: a) Regardless of your insurance type (health insurance, auto claim, W/C claim, attorney case, selfpay, that you understand what your accountability and responsibility is in each situation. b) PTSMC has verified your insurance benefits and eligibility and we are disclosing your financial responsibility, per your insurance plan guidelines. c) You, the patient, agree to be treated here at PTSMC by a licensed therapist. d) You, the patient, agree to assign all entitled medical benefits to PTSMC and that you authorize the release of information to any associated insurance, third party or legal entity. Section Nine The HIPPA Disclosure explains who PTSMC has authorization to release information to as well as YOUR privacy rights. Please read. Section Ten PTSMC has a very strict No-Show (NS) and Cancellation (Cx) policy. Please read this section carefully and sign. Section Eleven. Attorney Authorization If there is an attorney assigned to your case (auto, W/C), this form must be executed by you and your attorney, verifying the attorney s involvement and responsibility as well as your authorization. Please sign and date this form and submit to us to have it signed by your attorney.
Section Twelve The Personal Injury Protection (PIP) Disclosure fully explains the procedure that needs to be followed in all auto accident cases. Section Thirteen The Pain chart is simply a body drawing that gives the therapist a quick visual of the location of your pain and the type of pain sensations you are experiencing.
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 -PATIENT INFORMATION- SECTION ONE: PATIENT DEMOGRAPHICS Social Security#: - - Patient Name: Address: City: State: Zip: Guarantor Name (if applicable): Appointment Date: / / Day Time Phone:( )- - Birth Date: / / Age: Sex: Marital Status: Phone: Email Address: Primary Care Physician/ PCP: Work Phone:( )- - PCP's Phone: ( )- - *How did you hear about our facility? ======================================================================================= SECTION TWO: REFERRAL INFORMATION Name of physician who referred you to physical therapy: Referring physician s Phone: ( ) - - Fax: ( )- - Accident/Injury/Onset Date: / / Reconstructive Surgery: Y or N Emergency Contact: Relationship: Contact Phone: ( )- - SECTION THREE: AUTO ACCIDENT OR WORKERS COMPENSATION CASES 3A) Is this an Auto Accident claim? Y N If Yes, skip to 3B. If No, skip to (3vii) 3B) Accident/Injury Date: 3C) What is YOUR primary auto insurance company s name? 3Ci) Your auto claim number: 3cii) Claim adjuster s name:
3Ciii) Claim adjuster s phone and fax: 3civ) Has your adjuster approved physical therapy visits? Keep in mind that PTSMC MUST have proper verification from the adjuster that this claim is approved BEFORE you can be scheduled for an appointment. 3V) Have you submitted your PIP application? Y N. Please refer to Section 10 for the PIP Disclosure. 3VI) Is this a W/C claim? Y N 3vii) W/C claim number: 3viii) W/C Case adjuster Name: 3ix) W/C case adjuster Phone: ( ) - - Fax: ( ) - - SECTION FOUR LITIGATION CASES Is there an attorney assigned to this case: Y N If yes, please print the name of the law firm / attorney: Attorney Phone: ( )- - Fax:( )- - Have you signed PT&SMC s Attorney Authorization (AA) form attached? Y N SECTION FIVE HEALTH INSURANCE If you do NOT have health insurance and wish to pay out-of-pocket, skip to section 6. -PRIMARY INSURANCE- Primary Health Insurance: Policy #: Group#: Insured Name: Subscriber Name: Subscriber DOB: Insurance Phone: ( )- - ext.: Fax ( )- - -SECONDARY INSURANCE- Secondary Health Insurance: Policy #: Group#: Insured Name: Subscriber Name: Subscriber DOB: Insurance Phone: ( )- - ext.: Fax ( )- -
SECTION 6 SELF-PAY PATIENTS Please initial this section. I do Not have health insurance. I understand that the PTSMC self-pay charge per visit, is $75.00 I understand that this payment MUST be made AT THE TIME OF SERVICE, at each appointment. NO EXCEPTIONS.
Physical Therapy & Sports Medicine Center SECTION 7 PATIENT MEDICAL HISTORY Patient's Name: Birth Date: / / Age: Cell or Home Phone:( )- - Accident/Injury/Onset Date: / / Have you had surgery for this injury? YES NO (if yes) Number of Surgeries: Type of Surgery: Took Place in: Hospital Surgery Center Other: * Current Level of Pain Between 0-10 (0 being no pain, 10 being pain requiring ER care) * Are You Currently Taking Any Prescription or Non-Prescription Medication? YES NO List Medications: Have you had any of the following medical or rehabilitation services for this injury/episode? YES NO YES NO Chiropractor CT Scan EMG/NVC General Prac. Massage Therapy MRI Myelogram Neurologist Occupational Therapy Orthopedist Physical Therapy Podiatrist ER Care X-Rays Other: -Do you now have or have you ever had ANY of the following?- YES NO YES NO Asthma, Bronchitis, or Emphysema Severe or Frequent Headaches Shortness of Breath/Chest pain Vision or hearing difficulties Coronary Heart Disease or Angina Numbness or Tingling Do you have a pacemaker? Dizziness or Fainting High Blood Pressure Weakness Heart Attack or Surgery Hernia Stroke/TIA Blood Clot/Emboli Bowel or Bladder Problems Varicose Veins Epilepsy/Seizures Allergies Thyroid Trouble/Goiter Any Pins or Metal Implants Anemia Joint Replacement Infectious Disease Diabetes Emotional/Psychological Problems Cancer or Chemotherapy/Radiation Arthritis/Swollen Joints Osteoporosis Gout Are You Pregnant? Sleeping Problems/Difficulties Do You Smoke? Leg/Ankle/K nee/foot Injury/Surgery Elbow/Hand/ Shoulder Injury Surgery Back/Neck Injury/Surgery List any other information that would assist us in your care Are you aware of what your diagnosis is? YES NO Based upon your awareness, what are your expectations/goals while in this program? 7500 Hanover Pkwy Ste. 103 Greenbelt MD 20770 Phone: 301.446.1644Fax: 301.446.1647 14999 Health Center Dr. Ste. 201 Bowie MD 20716 Phone: 240.245.4245 Fax: 240.245.4916 17902 Georgia Ave Ste. 100 Olney MD 20832 Phone: 301.774.1789 Fax: 301.774.1394 6510 Kenilworth Ave. Ste. 1100 Riverdale MD 20737 Phone: 240.770.8750 Fax: 240.770.8156
SECTION 8 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 FINANCIAL POLICY STATEMENT We bill your insurance carrier solely as a courtesy to you. You are responsible for the entire bill when the services are rendered. We require that arrangements for payment of your estimated share be made today. If your insurance carrier does not remit payment within 60 days, the balance will be due in full from you. In the event that your insurance company requests a refund of payments made, you will be responsible for the amount of money refunded to your insurance company. In the event your company establishes an internal usual and customary fee schedule, you will be responsible for the difference remaining. If any payment is made directly to you for services billed by us, you recognize an obligation to promptly remit same to Physical Therapy & Sports Medicine Center. The above does not apply for those patients that are considered Worker s Compensation. However, be advised if you claim Workers Compensation benefits and are subsequently denied such benefits, you may be held responsible for the total amount of charges for services rendered to you. I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees and attorney fees. ESTIMATED INSURANCE BENEFITS: Estimated patient payment Arrangements for payment of patient s share NOTE: Estimated coverage information is provided as a courtesy to our patients but is not intended to release them from total responsibility for their account balance. The above information has been read and explained to me. Patient/Guardian/Responsible Party Center Representative/Witness CONSENT FOR CARE AND TREATMENT Date Date I, the undersigned, do hereby agree and give my consent for Physical Therapy & Sports Medicine Center to furnish medical treatment to (please PRINT name) Considered necessary and proper in diagnosing or treating his/her physical and mental condition. Patient/Guardian Signature Date: BENEFIT ASSIGNMENT/ RELEASE OF INFORMATION I, hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled, including Medicare, Medicaid, private insurance and third party payers to Physical Therapy and Sports Medicine Center. A photocopy of assignment is to be considered as valid as the original. I, hereby authorize said assignee to release a information necessary including Medical Records to secure payment. Patient/Guardian Signature Date: 1
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 SECTION 9 Patient Authorization and Disclosure of Protected Health Information Statement of Privacy Act. We may disclose your health care information: 1. To other healthcare professionals within our practice for the purpose of treatment, payment or health care operations. 2. To insurance provider for the purpose of payment or health care operations. 3. To comply with State Workers Compensation laws 4. To public health employees for preventing/controlling disease and reporting infectious exposures. 5. In the course of any administrative of judicial proceeding or law enforcement purposes Under HIPPA Federal Privacy law, you have the right to: 1. Request restrictions on certain uses of your health care information 2. Inspect and copy your healthcare information 3. Receive an accounting or disclosures of your protected health information made by us. 4. You have a right to a paper copy of this Notice of Privacy Practices at any time, upon request. We reserve the right to amend this notice of Privacy Practices at any time in the future. We are required by law to maintain the privacy of your healthcare information. If you have any questions regarding this notice or if you want more information about your privacy rights, please contact us at 301.446.1644. My signature indicates my authorization and consent for Physical Therapy and Sports Medicine Center to use and disclose my protected health care information for the purposes of treatment, payment and healthcare operations as described above. Patient s Name (PRINT): Patient s Signature: Date:
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 SECTION 10 Cancellation and No-Show Policy We ask that you help us to serve you by keeping your scheduled appointment. Appointments that are missed or cancelled at the last minute are not able to be given to other patients who need an appointment. You must be on time, so that you can be given the full benefit of your therapy session. Any patient who arrives more than 15 minutes late may not be seen by the therapist, AND a cancellation charge of $50.00 will be applied. If a patient is running late, it is asked that you call our office and let us know so that we can inform the therapist. PT&SMC requires at least 24 hours-notice for appointment cancellation. Any appointment that is cancelled the same day or within less than 24 hours will result in a $50.00 cancellation fee. This fee must be paid before one can be checked in at the next appointment. No-shows are a $50 charge Understand that if you do not show up to an appointment, without notice to our office, any future scheduled appointments will be removed from the system. The $50 fee must be paid in order for the next appointment to be scheduled. Three episodes of not attending physical therapy (no-show) will result in patient discharge from therapy. In the case of medical emergency, proper documentation (doctor s note etc.) must be provided. *No exceptions!* The above information has been read and explained to me. I understand the office policy. Patient: Date 1
7500 Hanover Pkwy Ste. 103 Greenbelt, MD 20770 Phone: 301.446.1644 Fax: 301.446.2424 6510 Kenilworth Ave. Ste. 1100 Riverdale, MD 20737 Phone: 240.770.8750 Fax: 240.770.8156 Section 12 Personal Injury Protection (PIP) Disclosure If you have been involved in an auto accident and have come to our facility with a filed claim, by law, PT&SMC MUST bill your PIP insurance. In order for your automobile insurance company to pay physical therapy benefits from your Personal Injury Protection or PIP policy, you MUST fill out the PIP Application. You should have received an application from your insurance company in the mail. If not, please contact your PIP case adjuster to make sure it is filled out. If you have not completed your PIP application, your visits will NOT be paid for through your auto claim. You need to contact your insurance company and complete the PIP application in order to become eligible for the PIP policy to pay your physical therapy bills. Your attorney is NOT responsible for completing your PIP application. If you have an auto accident claim, this is the order in which your physical therapy claims will be processed: 1. PIP insurance will be billed, per the claim information provided. 2. In the event that PIP exhausts, your health insurance will be billed next, with a copy of the exhaustion letter from the PIP insurance company. (Please understand that once your health insurance is being billed, you will be responsible for payment in accordance with your health insurance plan deductibles/co-pay/co-insurance) 3. If there is an attorney assigned to the case, an AA form MUST be executed and the attorney will be sent a statement reflecting any visits that have not been paid for. 4. If PIP exhausts and there is no health insurance, attorney will be billed the balance. If PIP exhausts and there is no health insurance and no attorney, the patient is fully responsible for the balance of payment. Acknowledgement Disclosure: By signing this agreement you indicate your consent to the term and conditions as are set forth herein and that translation of this agreement in Spanish or any other language is not necessary. Once signed, this disclosure shall become binding in all terms and respects and enforceable in State of Maryland, U.S.A. Patient Name (PRINT) Patient Signature Date 1
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 SECTION 11 Attorney Authorization I, the undersigned attorney for patient, hereby agree to make payment directly to Physical Therapy & Sports Medicine Center when the above patient s case is closed. I the undersigned attorney also agree to advise Physical Therapy & Sports Medicine Center in writing within ten days of: 1. Written or verbal request for updated status of the case 2. The settlement of the case or any other significant change in status, especially if this precluded or alters payment of Physical Therapy & Sports Medicine Centers, services professional fees by the law firm or other parties involved in the case. 3. For any settlement amount less than PTSMC s patient statement amount, a paper trail must be provided by the third party, to PTSMC management. Attorney s Signature: Date: Patient s Signature: Date: