Swanson McArthur Physical Therapy

Swanson McArthur Physical Therapy PATIET IFORMATIO SHEET CHART#: AME: DATE: SS#: ADDRESS: CIT: STATE: ZIP: HOME PHOE: CELL PHOE: EMERGEC COTACT AME: EMERGEC COTACT PHOE #: EMAIL ADDRESS: DATE OF BIRTH: AGE: SEX: M F MARITAL STATUS: M S D W EMPLOER: JOB TITLE: BUSIESS ADDRESS: CIT: STATE: ZIP: WORK PHOE: EXT: SUPERVISOR: HAVE OU SIGED OVER OUR MEDICARE BEEFITS TO KAISER, SECURE HORIZO, ETC? PRIMAR ISURACE COMPA: ADJUSTOR: ADDRESS: CLAIM #: PHOE #: CIT: STATE: ZIP: SECODAR ISURACE COMPA: ADDRESS: PHOE#: CIT: STATE: ZIP:. WORK RELATED?: MOTOR VEHICLE ACCIDET?: PERSOAL IJUR?: REFERRIG PHSICIA: DATE OF IJUR: HOW DID OU HEAR ABOUT OUR CLIIC? (Friend, Patient, Internet, Physician, etc):

PATIET HISTOR IFORMATIO Have you had previous Physical Therapy for your present condition? Where: Date(s): DO OU HAVE, OR HAVE OU HAD, A OF THE FOLLOWIG: (Circle es or o and give approximate date for each es). DIABETES HIGH BLOOD PRESSURE HEART DISEASE HEART ATTACK METAL IMPLATS PREVIOUS SURGER KIDE PROBLEMS ERVOUS DISORDERS CACER OSTEOPOROSIS y PACEMAKER SEIZURES PREGAT (CURRETL) HEADACHES HERIA ALLERGIES (MEDICATIO) ALLERGIES (HEAT OR ICE) ALLERGIES (CHLORIE) THROID DSFUCTIO Are you presently taking any medications? If yes, please list medications and for what conditions they are being taken, or provide us with a list to photocopy: OFFICE FIACIAL POLIC We require that you notify us 24 hours in advance if you are unable to attend a scheduled appointment. If you fail to cancel your appointment, you may be subjected to a "O-SHOW"/CACEL charge. I understand that, regardless of insurance, I remain personally responsible for the total amounts due to SWASO McARTHUR PHSICAL THERAP for services rendered. I authorize the release of any medical information necessary to process my claim. I also request payment of government benefits either to myself or to SWASO McARTHUR PHSICAL THERAP. SWASO McARTHUR PHSICAL THERAP accepts assignment from Medicare. If you have secondary insurance, please provide the name and policy number in order for us to coordinate benefits. Medicare requires a new referral every 30 days from your physician. This is a must, no exceptions. I authorize payment of medical benefits to SWASO McARTHUR PHSICAL THERAP for the services described on my claim. Patient Signature: Date: COSET TO TREAT I understand that I am under the care and control of my physician(s) and that SWASO McARTHUR PHSICAL THERAP is not liable for any act or omission when providing treatment in accordance with my physician's instructions. I consent to have SWASO McARTHUR PHSICAL THERAP provide the treatment and care prescribed by my physician. I understand this consent may be revoked by me at any time. Patient Signature: Date: Swanson McArthur Physical Therapy 6601 Madison Ave., Suite 200 Carmichael, CA 95608 p: 916 965-8900 www.swansonmcarthurpt.com

Swanson McArthur Physical Therapy Patient Guidelines 1. We have set aside time for you. Please be prompt and consistent in keeping your appointments. 2. ou should be seeing your referring doctor regularly while attending physical therapy. Please keep us informed AHEAD OF TIME of the dates you will be seeing your doctor so that we may prepare a letter to keep him/her informed of your progress. 3. Illness and/or emergencies sometimes occur. Please give us as much notice as possible if you must cancel an appointment. 24 hours is preferred. As a courtesy to us please call if you are unable to make your appointment. Do not be a "O-SHOW". We may be able to give that time to someone else if we have enough notice. ou may be subject to a $25.00 "no-show", late cancellation fee. 4. If you have a co-pay with your insurance, it is due at the time of each visit, or at the last visit of each week. Please choose what will work best for you, and make arrangements with the front office. 5. If your yearly deductible has not been met, we will bill you as a courtesy, and regular payments may be made until it has been satisfied. our co-pay will be due as stated above. 6. It is your responsibility to know the details of your insurance. 7. If you are a worker's compensation patient, please note that we are obligated to inform your insurance carrier with regards to the consistency of your attendance. For your health and quick recovery, please keep your scheduled appointments. 8. Please be consistent in following through with any instruction given regarding home care or home exercise. Initial: Date: "Restoring function, maximizing performance."

IDIVIDUAL PATIET'S AUTHORIZATIO (otice of Privacy Practices) THIS FORM IS TO COFIRM OUR AUTHORIZATIO TO USE OR DISCLOSE OUR PROTECTED HEALTH IFORMATIO FCR A SPECIAL PURPOSE. PSCHOTHERAP OTES: Check here if this authorization is for psychotherapy notes. If this authorization is for psychotherapy notes, it may not authorize the use or disclosure of any other type of protected health information. 1. IDIVIDUAL PATIET (OR PERSOAL REPRESETATIVE) COFIRMIG THE AUTHORIZATIO. I give my authorization to use or disclose my protected health information as described in Section 2 below. I give this authorization voluntarily. Individual Patient's ame: our Address: See File our Telephone umber: See File our E-Mail Address: See File our Patient Account umber: See File our Social Security umber: See File 2. THE USE AD/OR DISCLOSURE AUTHORIZED Describe in detail the protected health information you are authorizing to be used and/or disclosed (if this authorization is for psychotherapy notes, no other type of protected health information may be listed here): Health information related to my need for Physical Therapy ame the people and/or organizations (or the kinds of people and/or organizations) that you are authorizing to use and/or to disclose the protected health information described above. Swanson McArthur Physical Therapy Swanson McArthur Physical Therapy - Billing Service Swanson McArthur Physical Therapy - Collection Agency Swanson McArthur Physical Therapy - Worker's Compensation Authorization Contractor ame the people and/or organizations (or the kinds of people and/or organizations) that you are authorizing to receive and use your protected health information. Spouse and Parent/Guardian Swanson McArthur Physical Therapy - Billing Service Swanson McArthur Physical Therapy - Collection Agency Swanson McArthur Physical Therapy - Worker's Compensation Authorization Contractor

IDIVIDUAL PATIET'S AUTHORIZATIO (continued) Describe each purpose for which you are authorizing your protected health information to be used and/or disclosed. Treatment and Billing 3. EDIG THIS AUTHORIZATIO Select one of the following two choices. This authorization will end on the following date: This authorization will end when the following event happens. The event must relate to the individual or the purpose of the authorized use and/or disclosure. Describe the event below: UPO PATIET REQUEST 4. CHAGIG OUR MID ABOUT THIS AUTHORIZATIO I understand that I may revoke this authorization at any time by giving written notice to the Privacy Officer at your office. However, I understand that I may not revoke this authorization for any actions taken before receipt of my written notice to revoke this authorization. In addition, I understand that if I am giving this authorization as a condition of obtaining insurance coverage, and I revoke this authorization, the insurance company has a right to contest my claims under the insurance policy. 5. SIGIG THIS AUTHORIZATIO IS OT A CODITIO OF TREATMET I understand that under most circumstances a healthcare provider may not condition treatment, payment, enrollment, or eligibility for benefits on my signing this authorization. However, I understand that signing an authorization that permits the use and/or disclosure of my protected health information for research purposes may be a condition of my treatment if I am undergoing research-related treatment. Also, I may be required to sign an authorization if my treatments 'provided solely for the purpose of creating protected health information for disclosure to a third party. And under some circumstances, a health plan may condition my enrollment in a health plan or my eligibility for benefits on my providing an authorization permitting the health plan to make enrollment and eligibility determinations. 6. IDIVIDUAL PATIET'S SIGATURE I have had the chance to read and think about the content of this authorization form and I agree with all statements made in, this authorization. I understand that, by signing this form, I am confirming my authorization for use and/or disclosure of the protected health information described. in this form with the people and/or organizations named in this form. Signature: Date: If this authorization form is signed by a personal representative for the individual patient: Personal Representative's ame: Print name Signature Relationship to Individual Patient: OU HAVE A RIGHT TO HAVE A COP OF THIS FORM AFTER OU SIG IT. individual patient's medical record. Submit the authorization to the Privacy Official and include a copy in the

otice of Privacy Practices 7. ACKOWLEDGEMET FORM I have received the otice of Privacy Practices and I have been provided an opportunity to review it. ame: Birth date: Signature: Date: