Background Information & Medical History Form

Similar documents
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D

Grey Physical Therapy and Sports Medicine Center

Welcome to Back Country Physical Therapy, Intake Form

Orthopedic Initial Questionnaire. Date: Weight:

Orthopedic Initial Questionnaire

EASTERN CONNECTICUT REHABILITATION CENTERS PHYSICAL THERAPY INFORMATION PACKET

Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip

Medical History Questionnaire

WELCOME PATIENT CONDITION

DATE OF BIRTH SOCIAL SECURITY (Last 4 digits): SEX: Male Female

Advantage Physical Therapy Patient Registration

New England Pain Management Consultants At New England Baptist Hospital

THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS!

460 Main St, East. Unit M3 Hamilton, ON L8N 1K4 T: F:

SOUTH TAMPA MULTIPLE SCLEROSIS CENTER

Personal Injury Intake Form

PAIN MANAGEMENT. Patient s name: IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT.

PATIENT INFORMATION: PATIENT CONTACT PHONE NUMBERS: PHYSICIAN INFORMATION: HEALTH INSURANCE INFORMATION:

New Patient Registration Information

REHAB RESOURCES, INC. CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over)

Welcome to Tri-State Rehab Services

THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History

Cancellation/No Show Policy

Work Injury Information Continued

DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS

Acknowledgement of Receipt of Notice of Privacy Practices

6. Do you have an Advance Directive or Living Will? Yes No These are written statements about how you want to be treated if you get very sick.

Thank you for choosing ALTITUDE PHYSICAL THERAPY, a Member of the P3 Network - PT-MD Kinect LLC & Partners in Health Healing Center

Home Phone#: Mobile #: Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone: ( )

Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,

New Patient Intake Form

MILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE

Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Address

NEW PATIENT HISTORY Mark L. Prasarn, M.D.

SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/ CARE GIVER QUESTIONNAIRE

St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?

PATIENT INFORMATION INSURANCE INFORMATION

Workers Compensation Form

Emory Eye Center New Patient Questionnaire

General Internal Medicine Clinic New Patient Questionnaire

*2PHT* REHAB SERVICES PATIENT HISTORY QUESTIONNAIRE

Workman s Compensation

Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)

PATIENT REGISTRATION

My health action plan

Life Insurance Pre-assessment Request

Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach

JAMES PETROS, M.D., INC. PHONE: (408) FAX: (408)

Therapeutic Massage .(W). Chiropractor

City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip:

San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet

AON Physical Therapy & Wellness

NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH Phone: Fax:

SPINE PATIENT HISTORY FORM

Patient Information Form Pain Management Center at Phoebe

PATIENT INFORMATION INSURANCE INFORMATION

TORREY PINES ORTHOPAEDIC MEDICAL GROUP Workers Compensation History Form. Date: Physician: Type of Evaluation: Patient: Height: Weight:

Fran, Medical Assistant Kim, Office Manager, Referral Coordinator, Billing Specialist

Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )

How To Write A Medical History Questionnaire For An Aransas Plastic Surgery

Welcome to Avida PT. The purpose of this letter is to provide you with some helpful information to prepare you for your visits to our facility.

MEDICAL HISTORY AND SCREENING FORM

Please fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at

Welcome to the UW Health Sports Medicine Clinic

Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD

Insurance (Let us make a copy of your insurance card and you can skip this section)

PATIENT HISTORY FORM

RIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form

Male New Patient Package

VEIN CLINIC OF NORTH CAROLINA 3318 HEALY DR. WINSTON SALEM, NC PH FAX Scott W. Baker, MD. Patient Instructions

PREMIER PLASTIC SURGERY CENTER OF NEW JERSEY 310 MADISON AVENUE, SUITE 100, MORRISTOWN, NJ PHONE: FAX:

Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other:

Empower Physical Therapy

Liver Disease & Hepatitis Program Providers: Brian McMahon, MD, Steve Livingston, MD, Lisa Townshend, ANP. Primary Care Provider:

NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION

Dr. David Y. Liao, D.O. Orthopedic Center, LLC. Release of Information

Westoaks Orthopaedic Associates

Integrated Medical Services (IMS) New Patient Registration Sheet

Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas Today s Date: How did you hear of our practice?

Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL Phone: Fax:

Patient Questionnaire for Men

NORTHERN EDGE PHYSICAL THERAPY

Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL Phone: Fax:

William O. Reed, Jr. M.D., P.A W. 74 th Street, Suite 354 Overland Park, KS Fax:

Transcription:

Background Information & Medical History Form To ensure you receive a complete and thorough evaluation, please provide us with information regarding your health status found on this form. If you do not understand a question, leave the area blank and your therapist will assist you. Thank you! Name: Date: Are you Working at your usual job with no restrictions. Have you ever had physical therapy currently: Working at your usual job with restrictions. for this condition? (check one) Unable to work because of your condition since: Unable to work due to other medical reasons. Circle: YES NO Retired / Unemployed / Homemaker Are you Medical Doctor Dentist Psychiatrist/Psychologist seeing: Osteopath Physical therapist Chiropractor If you have seen any of the above during the last three months, please describe the reason (illness, medical conditions, injury, routine physical, etc.). Have you EVER been diagnosed as having any of the following conditions: Yes No Heart Problems Yes No Hearing loss/disorder Yes No Circulation Problems Yes No High blood pressure Yes No Eye Disease Yes No Osteoporosis Yes No Stroke Yes No Muscle disease/disorder Yes No Cancer: Yes No Rheumatoid Arthritis Yes No Multiple Sclerosis If yes, what kind: Yes No Other Arthritic Problems Yes No Diabetes Yes No Past Pregnancy: Yes No Epilepsy Yes No Tuberculosis Delivery (please circle): vaginal cesarean Yes No Lung Disease Yes No Hepatitis Yes No Currently Pregnant? months Yes No Emphysema/Bronchitis Yes No Kidney Disease Yes No Other: Yes No Asthma Yes No Thyroid Problems Yes No Chemical Dependency Yes No Depression Please list any surgeries or other conditions for which you have been hospitalized, including dates and reasons. Date SURGERY REASON: Please describe any injuries for which you have been treated (fractures, dislocations, sprains/strains). Date INJURY Date INJURY Has anyone in your immediate family (parents, brothers, sisters) ever been treated for the following? Yes No Diabetes Yes No Epilepsy Yes No Cancer Yes No Heart disease Yes No Chemical dependency Yes No Headaches Yes No Arthritis Yes No Tuberculosis Yes No Mental Illness Yes No High blood pressure Which of the following OVER-THE-COUNTER medications have you taken in the past week? Yes No Aspirin Yes No Decongestants Yes No Antihistamines Yes No Advil/Motrin/Ibuprofen Yes No Antacids Yes No Vitamins/Mineral Supplements Yes No Tylenol Yes No Laxatives Yes No Other: List all PRESCRIPTION medicines you are currently taking (pills, injections, and skin patches): Medicine Allergies: How much caffeine per day? Cigarettes smoked per day? Days a week you drink alcohol? Have you recently noted: Yes No Weight loss/gain Yes No Weakness Yes No Menstrual Irregularities Yes No Nausea/Vomiting Yes No Fever/Chills/Sweats Yes No Bladder Irregularities Yes No Fatigue Yes No Numbness or tingling Yes No Rectal Bleeding Form reviewed with patient: YES NO Therapist signature:

SYMPTOMDIAGRAM Patient sname Date Usethefollowingdrawingtoindicatethelocationofyoursymptomsatthepresenttime. Usethevarioussymbolstodescribethesymptoms. SHARPPAINACHINESSBURNINGPINSANDNEEDLESNUMBNESS ////XXX!!!!0000++++ Instructions:Rateyourmajorareaofpainonthe0 10PainRatingScalebelow: 012345678910 NopainWeakModerateStrongVeryStrongMaximalPain Pleaserateyourpain(0 10)atrestandwithactivityinthespacesprovided: WithActivity AtRest

APPLE PHYSICAL THERAPY CANCELLATION/NO SHOW POLICY Apple Physical Therapy takes the subject of canceling your appointment very seriously, as it can make the difference as to whether you recover from your injury or condition. Showing up as scheduled is one of your most important responsibilities. Apple Physical Therapy requires 24 hours notice for the cancellation of a scheduled appointment. Please have an alternative appointment time in mind for that week when you call to cancel. It is important that you receive your full amount of prescribed treatment since many insurance companies restrict physical therapy benefits. Your prescribed number of visits is determined by your physical therapist after your initial evaluation. There is a $20 charge for a no show or cancellation WITHOUT proper notice. This charge will NOT be covered by your insurance, but will have to be paid by you personally. We take this policy seriously because when a patient misses an appointment, three people are adversely affected: 1.) You, the patient for not receiving the treatment you need. 2.) Your therapist as now he or she has an empty space in the schedule, since the time was reserved for you personally. 3.) Another patient who could have had your appointment time to receive treatment. Sometimes, you may feel you should not attend physical therapy for the following reasons 1.) You may continue to have pain or feel your pain is worsened. Please understand your pain may fluctuate as your course of treatment progresses and before you complete therapy. It is important to come in if you are in pain because there are treatments available that can lessen those symptoms. 2.) You are experiencing less pain. This is also not a reason to cancel or fail to show for your scheduled treatment. That is the point in your treatment progression to begin correction of the underlying causes of your problem and educate you as to how to avoid re injury in the future. As you can see, neither of these reasons are legitimate reasons to not keep your scheduled appointment. Please cooperate with us in this regard, and we will have you out of pain and feeling better soon. We are looking forward to working with you. I consent to the above, as indicated by my signature below: (print name) (signature) (Date)

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

PurposeofNotice NOTICEOFPROTECTEDHEALTHINFORMATIONPRACTICES THISNOTICEDESCRIBESHOWMEDICALINFORMATIONABOUTYOUMAYBE USEDANDDISCLOSEDANDHOWYOUCANGETACCESSTOTHISINFORMATION PLEASEREVIEWITCAREFULLY UnderthefederalhealthcareprivacyregulationspertainingtotheHealthInsurancePortabilityandAccountabilityActof1996setforthat45 160.101etseq.(the PrivacyRegulations ),ApplePhysicalTherapy( ThePractice ),isrequiredtoprotecttheprivacyofyourindividuality identifiablehealthinformation,whichincludesinformationaboutyourhealthhistory,symptoms,testresults,diagnoses,treatmentandclaimsand paymenthistory.wearealsorequiredtoprovideyouwiththisnoticeofprotectedhealthinformationpracticesregardingourlegalduties,policies andprocedurestoprotectandmaintaintheprivacyofyourhealthinformation( thenotice ).Wewillnotuseordiscloseyourhealthinformation exceptasprovidedforinthisnotice.however,wereservetherighttochangethetermsofthisnoticeandmakenewnoticeprovisionsforallyour healthinformationthatwemaintain. PermittedUsesandDisclosuresofYourHealthInformation 1.UsesandDisclosureswithPatientConsent:UnderthePrivacyRegulations,afterhavingmadegoodfaitheffortstoobtainyour acknowledgementofreceiptofthisnotice,wearepermittedtouseanddiscloseyourhealthinformationforthefollowingpurposes: a.treatment:wearepermittedtouseyourhealthinformationintheprovisionandcoordinationofyourhealthcare.wemaydiscloseinformation containedinyourmedicalrecordtoyourprimaryhealthcareprovider,consultingproviders,andtootherhealthcarepersonnelwhohaveaneedforsuch informationforyourcareandtreatment.forexample,yourphysicaltherapistmaydiscloseyourhealthinformationwhenconsultingwithaphysicianregardingyour medicalcondition. b.payment:wearepermittedtouseyourhealthinformationforthepurposeofdeterminingcoverage,billing,claimsmanagement,medicaldata processingandreimbursement.thisinformationmaybereleasedtoaninsurancecompany,thirdpartypayororanotherauthorizedentitiesinvolvedinthepayment ofyourmedicalbillandmayincludecopiesorportionsofyourmedicalrecordwhicharenecessaryforpaymentofyouraccount.forexample,abillsenttoyour insurancecompanymayincludeinformationthatidentifiesyou,yourdiagnosisandtheproceduresandsuppliesusedinyourtreatment. c.healthcareoperations:wearepermittedtouseanddiscloseyourhealthinformationduringthepractice sroutinehealthcareoperations,including, butnotlimitedto,qualityassurance,utilizationreviews,medicalreviews,auditing,accreditation,certification,licensingorcredentialingactivitiesandforeducation purposes. 2.UsesandDisclosureswithPatientAuthorization:UnderthePrivacyRegulations,wecanuseanddiscloseyourhealthinformationforpurposes otherthantreatment,paymentorhealthcareoperationswithyourwrittenauthorization.forexample,withyourauthorizationwecanprovide yournameandmedicalconditiontocompanieswhomightbeabletoprovideyouusefulitemsorservices.undertheprivacyregulations,you mayrevokeyourauthorization,however,suchrevocationwillnothaveanyeffectonusesordisclosuresofyourhealthinformationpriortoour receiptoftherevocation. 3.UsesandDisclosureswithPatientOpportunitytoVerballyAgreeorObject:UnderthePrivacyRegulations,wearepermittedtodiscloseyour healthinformationwithoutyourwrittenconsentorauthorizationtoafamilymember,aclosepersonalfriendoranyotherpersonidentifiedby you,iftheinformationisdirectlyrelevanttothatperson sinvolvementinyourcareortreatment.youmustbenotifiedinadvanceoftheuseor disclosureandhavetheopportunitytoverballyagreeorobject. 4.UsesandDisclosureswithoutanAcknowledgement,AuthorizationorOpportunitytoVerballyAgreeorObject:UnderthePrivacyRegulations, wearepermittedtouseordiscloseyourhealthinformationwithoutyourconsent,authorizationortheopportunitytoverballyagreeorobject withregardtothefollowing: a.useanddisclosuresrequiredbylaw:wewilldiscloseyourhealthinformationwhenrequiredtodosobylaw. b.publichealthactivities:wemaydiscloseyourhealthinformationforpublichealthreporting,reportingofcommunicablediseasesandvitalstatistics andsimilarothercircumstances. c.abuseandneglect:wemaydiscloseyourhealthinformationifwehavereasonablebeliefofabuse,neglectordomesticviolence. d.regulatoryagencies:wemaydiscloseyourhealthinformationtoahealthcareoversightagencyforactivitiesauthorizedbylawincluding,butnot limitedto,licensure,certification,audits,investigationsandinspections.theseactivitiesarenecessaryforthegovernmentandcertainprivatehealthoversight agenciestomonitorthehealthcaresystem,governmentprogramsandcompliancewithcivilrights. e.judicialandadministrativeproceedings:wemaydisclosehealthinformationinjudicialandadministrativeproceedings,aswellasinresponsetoan orderofacourt,administrativetribunal,orinresponsetoasubpoena,summons,warrant,discoveryrequestorsimilarlegalrequests. g.coroners,medicalexaminers,funeraldirectors:wemaydiscloseyourhealthinformationtocoronerormedicalexaminer.thismaybenecessary,for example,todetermineacauseofdeath.wemayalsodiscloseyourhealthinformationtofuneraldirectors,asnecessary,tocarryouttheirduties. h.research:undercertaincircumstances,wemaydiscloseyourhealthinformationtoresearcherswhentheirclinicalresearchstudyhadbeenapproved byaninstitutionalreviewboardthathasreviewedtheresearchproposalandprovidedthatcertainsafeguardsareinplacetoensuretheprivacyandprotectionof yourhealthinformation. i.threatstohealthandsafety:wemayuseordiscloseyourhealthinformationifwebelieve,ingoodfaith,theuseordisclosureisnecessarytoprevent orlessenaseriousorimminentthreattothehealthorsafetyofapersonorthepublic.

j.military/veterans:ifyouareamemberofthearmedforces,wemaydiscloseyourhealthinformationasrequiredbymilitarycommandauthorities. k.workers Compensation:Wemaydiscloseyourhealthinformationtotheextentnecessarytocomplywithlawsrelatingtoworkers compensationor othersimilarprograms. l.marketing:wemayuseordiscloseyourhealthinformationtomakeamarketingcommunicationtoyou,ifsuchcommunicationisconductedface toface,concernsproductsorservicesornominalvalue,oridentifiesusasthecommunicatingpartyandthatwewillreceiveremunerationformakingthe communicationand,whererequiredbytheprivacyregulations,instructionsdescribinghowyoumayverballyobjecttoreceivingfuturecommunications. m.appointmentreminders:wemayuseanddiscloseyourhealthinformationtoremindyouofanappointmentfortreatmentandmedicalcareatour practice. n.otherusesanddisclosures:inadditiontothereasonsoutlinedabove,wemayuseanddiscloseyourhealthinformationforotherpurposespermitted bytheprivacyregulations. 5.UseandDisclosurestoBusinessAssociates:Withanacknowledgementoraproperauthorization,wearepermittedtodiscloseyourhealth informationtobusinessassociatesandtoallowbusinessassociatestoreceiveyourhealthinformationonourbehalf.abusinessassociateis definedundertheprivacyregulationsasanindividualorentityundercontractwithustoperformorassistusinafunctionoractivitywhich requirestheuseofyourhealthinformation.examplesofbusinessassociatesinclude,butarenotlimitedtoconsultants,accountants,lawyers, medicaltranscriptionistsandthirdpartybillingcompanies.werequireallbusinessassociatestoprotecttheconfidentialityofyourhealth information. PATIENTRIGHTS Althoughyourmedicalrecordisourproperty,youhavethefollowingrightsconcerningyourmedicalrecordandhealthinformation: 1.RighttoRequestRestrictionsontheUseandDisclosureofYourHealthInformation:Youhavetherighttorequestrestrictionsontheuseand disclosureofyourhealthinformationfortreatment,paymentandhealthcareoperations.however,wearenotrequiredtoagreewithsucha request.ifhowever,weagreetotherequestedrestrictions,itisbindingonus. 2.RighttoInspectandCopyyourHealthInformation:Youhavetherighttoinspectandcopyyourownhealthinformationuponrequest. however,wearenotrequiredtoprovideyouaccesstoallthehealthinformationthatwemaintain.forexample,thisrightdoesnotextendto psychotherapynotes,informationcompiledinreasonableanticipationof,orforusein,acivil,criminaloradministrativeproceeding,orsubject toorexemptfromclinicallaboratoryimprovementsamendmentsof1988.accessmayalsobedeniedifdisclosurewouldreasonablyendanger youoranotherperson. 3.RighttoVerballyObject:Youhavetherighttoverballyobjecttocertaindisclosuresthatareroutinelymadefortreatment,paymentorhealth careoperationsorforotherpurposeswithoutanauthorization.forexample,wearerequiredtogiveyouanopportunitytoobjecttothe sharingofyourhealthinformationwithapersonorfamilymemberaccompanyingyoufortreatment. 4.RighttoSeekanAmendmentofYourHealthInformation:Youhavetherighttorequestanamendmentofyourhealthinformation.Ifwe disagreewiththerequestamendment,wewillpermityoutoincludeastatementintherecordmoreover,wewillprovideyouwithawritten explanationofthereasonsforthedenialandtheproceduresforfilingappropriatecomplaintsandappeals. 5.RighttoanAccountingofDisclosureofYourHealthInformation:Youhavetherighttoreceiveanaccountingofdisclosuresmadebyusofyour healthinformationwithinsix(6)yearspriortothedateofyourrequest,provided,howeverthatweneednotprovideanaccountingforany informationdisclosedpriortoapril14,2003.theaccountingwillnotincludedisclosuresrelatedtotreatment,paymentorhealthcare operations,disclosuresmadetoyou,disclosuresmadepursuanttoavalidlyexecutedauthorization,disclosurespermittedbytheprivacy regulations,disclosurestopersonsinvolvedinyourcare,ordisclosuresthatoccurredpriortotheapril14,2003compliancedeadlineunderthe privacyregulations.theaccountingofdisclosuresshallincludethedateofeachdisclosure,nameandaddressofthepersonororganization whoreceivedyourhealthinformation,abriefdescriptionoftheinformationdisclosed,andthepurposeforthedisclosure. 6.RighttoConfidentialCommunications:Youhavetherighttoreceiveconfidentialcommunicationsofyourhealthinformationbyalternative meansoralternativelocations.forexample,youmayrequestthatweonlycontactyouatworkorbymail. 7.RighttoRevokeYourAuthorization:Youhavetherighttorevokeavalidlyexecutatedauthorizationfortheuseordisclosureofyourhealthinformation. However,suchrevocationwillnothaveanyeffectonusesordisclosurespriortothereceiptoftherevocation. 8.RighttoReceiveCopyofthisNotice:Youhavetherighttoreceiveacopyofthisnotice. ContactInformationandHowtoReportaPrivacyRightsViolation Ifyouhavequestionsandwouldlikeadditionalinformationregardingtheusesanddisclosuresofyourhealthinformation,youmaycontacttheComplianceOfficerat (856)751 2140.Moreover,thePracticehasestablishedaninternalcomplaintprocessforreportingprivacyrightsviolations.Ifyoubelievethatyourprivacyrights havebeenviolated,youmayfileacomplaintwithusorthesecretaryofthedepartmentofhealthandhumanservicesat200independenceavenue,s.w., Washington,D.C.20201.Tofileacomplaintwithus,pleasecontacttheComplianceOfficerat(856)751 2140.AllcomplaintsmustbesubmittedtothePracticein writingat16rockhillroad,suitea,cherryhill,nj08003.therewillbenoretaliationforfilingacomplaint. EffectiveDate: TheeffectivedateofthisNoticeis4/14/03.

ACKNOWLEDGEMENTOFRECEIPTOFPRIVACYNOTICE PurposeofthisAcknowledgement ThisAcknowledgement,whichallowsthePracticetouseand/ordisclosurepersonalityidentifiablehealthinformationfortreatment,paymentor healthcareoperations,ismadepursuanttotherequirementsof45cfr 164.520(c)(2)(ii),partofthefederalprivacyregulationsfortheHealth InsurancePrivacyandAccountabilityActof1996(the PrivacyRegulations ). Pleasereadthefollowinginformationcarefully: 1.IunderstandandacknowledgethatIamconsentingtotheuseand/ordisclosureofpersonalityidentifiablehealthinformationaboutmebyApplePhysicalTherapy (the Practice )forthepurposeoftreatingme,obtainingpaymentfortreatmentofme,andasnecessaryinordertocarryoutanyhealthcareoperationsthatare permittedintheprivacyregulations. 2.IamawarethatthePracticemaintainsaPrivacyNoticewhichsetsforththetypesofusesanddisclosuresthatthePracticeispermittedtomakeunderthePrivacy RegulationsandsetsforthindetailthewayinwhichthePracticewillmakesuchuseordisclosure.BysigningthisAcknowledgement,Iunderstandandacknowledge thatihavereceivedacopyoftheprivacynotice. 3.IunderstandandacknowledgethatinitsPrivacyNotice,thePracticehasreservedtherighttochangeitsPrivacyNoticeasitseesfitfromtimetotime.IfIwishto obtainarevisedprivacynotice,ineedtosendawrittenrequestforarevisedprivacynoticetotheofficeofthepracticeatthefollowingaddress:applephysical Therapy,Attn:PracticeComplianceDirector16RockhillRoad,SuiteA,CherryHill,NJ08003 4.IunderstandandacknowledgethatIhavetherighttorequestthatthePracticerestricthowmyinformationisusedordisclosedtocarryouttreatment,payment orhealthcareoperations.iunderstandandacknowledgethatthepracticeisnotrequiredtoagreetorestrictionsrequestedbyme,butifthepracticeagreestosucha requestedrestrictionitwillbeboundbythatrestrictionuntilinotifyitotherwiseinwriting. IrequestthefollowingrestrictionsbeplacedonthePractice suseand/fordisclosureofmyhealthinformation(leaveblankifno restrictions:. Iunderstandtheforegoingprovisions,andIwishtosignthisacknowledgementauthorizingtheuseofmypersonallyidentifiablehealthinformation forthepurposeoftreatmentandhealthcareoperations. BYSIGNINGTHISFORM,IACKNOWLEDGETHATIHAVEREVIEWEDANEXECUTEDCOPYOFTHISACKNOWLEDGEMENTANDACOPYOFTHE PRACTICE SPOLICYNOTICEANDAGREETOTHEPRACTICE SUSEANDDISCLOSUREOFMYPROTECTEDHEALTHINFORMATIONFORTREATMENT, PAYMENTANDHEALTHCAREOPERATIONS. SignatureofpatientorRepresentative Date Patient sname DateofBirth SocialSecurityNumber NameofPersonalRepresentative(IfApplicable) RelationshiptoPatient TobeCompletedbythePractice Therequestedrestrictionsontheuseand/ordisclosureofthepatient shealthinformationsetforthaboveare: Accepted Denied NotApplicable Other(explain) SignatureofAuthorizedPracticeRepresentative Date

2026 © DocPlayer.net Privacy Policy | Terms of Service | Feedback  | Do Not Sell My Personal Information