Download Medicare Insurance Intake Packet

Patient Name _____________________________________ Marital Status ___________
Address
______________________________________ M / F
City
______________________________________ State _______ Zip _______
Home Phone _________________ Cell Phone ____________ SSN ________________
Birth Date _________________ Email ________________________
Employer
Job Title
________________________________
________________________________
Work Phone # _______________
Spouse / Parent Name _____________________________________________________
Address ________________________________________________________________
Birth Date _____________________________ SSN ____________________________
Employer __________________________________ Work Phone # _________________
Referring Physician ______________________________ Dte of Script ___________
Dx of Injury / Illness ______________________________________________________
Date of Injury / Surgery / Onset ______________________________________________
Does patient require social or vocational services? _______________________________
Was injury work related or related to an auto accident? ___________________________
INSURANCE INFORMATION
Primary Insurance Co. _____________________________________________________
Subscribers Name
________________________________SSN _________________
Birth Date of subscriber ______________________________
Policy # ___________________________________________ Group # ______________
Insurance Phone # ________________________________________________________
Secondary Insurance Co. ___________________________________________________
Subscribers Name
_____________________________ SSN __________________
Birth Date of subscriber _____________________________
Policy # __________________________________________ Group # _______________
Insurance Phone # ________________________________________________________
WORK COMP INFORMATION
Person to verify coverage ___________________________________________________
Phone # ____________________________Claim # ______________________________
Scheduled within 24-48 hours? ______ yes. If not, why?__________________________
Does patient have a living will? __________ yes. If yes, please provide copy on 1st visit.
Patient provided with directions to clinic and told to bring Rx, ins card and swimming
suit, if applicable etc.
(Office Use Only)
How did you hear about us?_______________
Therapist _______________
Appt Date/ Time _________
SYNERGY THERAPIES, LLC
Aquatic, Rehabilitation and Athletic Center
19049 Valley View Parkway, Suite H
Independence, MO 64055
021-0305
Synergy Therapies
How did you hear about Synergy Therapies? _______________________________________________
Acknowledgment of Receipt of Privacy Notice
By signing this form, you acknowledge that Synergy Therapies has given you a copy of its Privacy Notice.
Check all that are true.
__ I have received Synergy Therapies Privacy Notice
__ I have chosen not to receive the Privacy Notice
__ Synergy Therapies has given me the chance to discuss my concerns and questions about the privacy of
my health information.
___________________________
Patient/Guardian Signature
______________________
Date
Synergy Therapies should complete if Acknowledgment Form is not signed:
Does patient have a copy of the Privacy Notice? ______ Yes ______ No
Please explain why the patient was unable to sign an Acknowledgment form & Synergy Therapies efforts
in trying to obtain the patient’s signature:
______________________________________________________________________________________
__________________________________________________________
Staff signature
Consent To Use & Disclose Protected Health Information
As a condition of providing treatment to you, Synergy must obtain your consent to use and disclose
protected health information about you to carry out treatment, obtain payment and health care operations of
our office. This policy is to protect the patient and to also protect our staff from violating the patient’s
confidentiality.
You may revoke this consent at any time by notifying the office in writing, except to the extent the office
has taken action and reliance upon your consent. You have the right to request the office to restrict the
manner in which your protected health information is used or disclosed to carry out treatment, payment or
health care operations. The office is not required, however to agree to some requested restrictions.
I hereby consent to the use and disclosure by the office, its workforce and its business associated of my
protected health information for the purposes of treatment, payment and health care operations.
I give consent to Synergy Therapies to release and or leave a message regarding treatment or appointments
on the:
__Answering machine at home
__Voice mail at work
__Cell phone (cell phone #___________________)
__I do not consent to messages being left: Contact me directly
I give consent to Synergy Therapies to release any information to the named person/persons below.
________________________________ Relationship ________________________________
Additional Comments/Restrictions:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Signature of Patient or Guardian
Print Name
Synergy Therapies
PATIENT CONSENT, AUTHORIZATION & ASSIGNMENT OF BENEFITS
Patients Name _______________________
1. A description of the treatment ordered or recommended was explained to me.
2. Risks and benefits of treatment were explained.
3. Risks and benefits of going without treatment were explained.
4. Possible alternatives to the recommended treatment were discussed.
5. The initial treatment plan may need to be changed or additional treatment may be
ordered upon physician approval.
6. Billing policies have been discussed with me.
7. My questions regarding my care and treatment plan have been answered.
8. I hereby authorize Synergy Therapies to carry out all procedures as ordered by my
physician.
9. I authorize direct payment of benefits be made on my behalf to Synergy
Therapies. I understand and agree that I am ultimately responsible for all fees,
regardless of my insurance coverage.
10. I consent to the release of my medical records by Synergy Therapies for the
purpose of review or audits to my doctor, insurance company or adjustor
11. A photocopy of this assignment shall be considered as effective and valid as the
original.
The above items have been discussed with me, to my satisfaction, and I understand
and consent to the planned therapy treatment.
_____________________________
_____________________________
Patient/Guardian Signature
Date
*Treatment rendered without regard to race, color, national origin, disability and age.
Synergy Therapies
BILLING POLICY
Thank you for choosing us as your Health Care Provider. We are committed To
Your Treatment Being Successful.
Please understand that payment of your bill is considered a part of your treatment. A
combination of effort by you, our patient, and our insurance/business staff will assure that
your billing is handled promptly and properly. Although the patient is always responsible
for payment for therapy services, we work closely with your insurance company to report
your claims for reimbursement! Please read and sign prior to any treatment.
Regarding Insurance;
1. All claims will be filed with your insurance company, if applicable
2. Co- Payments will be due at each visit, if applicable
3. Medicare patients without 2ndary insurance will be responsible for Medicare
deductibles and co insurance balance.
4. We Do Not file third party billing as the result of auto accidents, falls or any other
accident in which you are filing a claim. We will not wait for settlement of your
claim to pay your balance due.
5. We will file secondary insurance claims on your behalf if applicable.
6. Statements will be sent monthly. The statement will indicate if it is your balance
after insurance payment has been made.
7. Acceptable forms of payment are Cash, Visa/MasterCard, Discover, American
Express and or check.
8. A service fee of 3% may be applied to any past due accounts.
9. If there is no insurance available the patient will pay $80.00 per visit towards the
balance of their account. Upon completion of treatment the balance will be due.
PLEASE NOTE THAT REGARDLESS OF INSURANCE BENEFITS WE RECEIVE FROM YOUR
INSURANCE COMPANY, THIS IS NOT A GUARANTEE OF PAYMENT AND YOU AS THE
PATIENT ARE ULTIMATELY RESPONSIBLE FOR YOUR TOTAL BILL. (SOME EXCEPTIONS
MAY APPLY TO WORKERS COMPENSATION)
Usual & Customary Rates:
Our practice is committed to providing the best treatment for our patients and we
charge what is Usual and Customary for our area. You are responsible for payment
regardless of any insurance company’s arbitrary determination of Usual & Customary
rates. (This applies to non contacted insurance carriers’)
Thank you for understanding our Billing Policy. Please let us know if you have
questions or concerns.
I have read the Billing Policy and understand and agree to this Billing Policy.
__________________________
Signature of patient / Guardian
___________________
Date
Synergy Therapies
Patient Accident Information
Patient Name_________________________
Patient Birth date _____________________
Type of Accident: (please circle one )
Auto Accident
Other Accident
No Accident
Date of Accident_________________
Third Party Information:
Insurance Company____________________________
Phone Number _______________________________
Address_____________________________________
Insured Name (if known)________________________
Adjustor Name________________________________ Claim #____________________
Patient’s Attorney Information:
Attorney Name____________________________________
Attorney Phone Number ____________________________
Signature_____________________________ Date_________________________
022-1006
AQUATIC IN-TAKE FORM
Synergy Therapies
Aquatic, Rehab, and Sports Clinic
Precautions: Please check if current
Contraindications: Please check if current
___ Hypotension
___ Open Draining Wounds*
___ Hypertension
___ Dermatological Problems – Active
Psoriasis
___ Decreased Pulmonary Function or Asthma
___ Urinary Tract Infection
___ Bladder Incontinence
___ Intravenous Lines
___ Involuntary Diarrhea or Bowel
Incontinence
___ Excessive Skin Sensitivity
___ Transmittable disease
___ Intolerance to Fluid Loss
___ Lice/Scabies
___ Poor Temperature Control
___ Unstable Blood Pressure/Incipient CHF
___ Cerebral Hemorrhage
___ Non-tunnel Catheters
___ Perforated Ear Drum
___ Deep Vein Thrombosis
___ Ear Infection
___ Fever over 100 Degrees F
___ Confusion/Disorientation
___ Premature Membrane Rupture in
Pregnancy
___ Agitation or Severe Behavior Problem
___ Epilepsy/Seizure Activity (controlled)
___ Menstruation – internal protection
___ Intoxication
___ Refluxive Ureter
___ Conjuctivitis
___ Fear of Water
___ Athlete’s Foot
___ HIV – Pool Chemicals may exacerbate
*Open skin areas such as post-operative surgical
incisions may be covered with a Bio-occlusive
Dressing such as Tega-derm if both clinician
and surgeon deem appropriate
___ Radiation Therapy
Hypersensitivity or Allergy to Chlorine/Bromine? ______
AQUATIC IN-TAKE FORM
Synergy Therapies
Aquatic, Rehab, and Sports Clinic
Thank you for choosing to participate in Synergy Therapies Aquatic Exercise program.
Please read through the items listed below to familiarize yourself with our facility, what is provided
for you and what you need to bring with you.
Provided:





Chair lift if unable to walk or on crutches
4 shower stalls
1 handicap accessible shower with toilet
Pool water temperature at 90-92 degrees Fahrenheit
Blood pressure cuff
Please Bring:
 Towel
 Bathing suit/swim trunks (wash in 30% vinegar/70% water)
 Rubber soled shoes (i.e. aqua socks, flips flops, crocks, etc.) are optional
 Change of clothes
 Bag or tote to place wet suit/trunks
 Hair dryer if necessary
 Personal grooming items
Entering Aquatic Area:
 Change in one of four available shower rooms
 Rinse off in the shower (this minimizes oils, lotions, deodorant, etc.
entering the pool and affecting balance of pool pH).
 Bring personal items out of shower room and place on shelf
 Enter pool via stairs or chair lift with clinician assistance
Comfort Level in Pool: Good_____
Fair_____
Poor_____
Explain concerns
I agree to and understand all that is written above and will comply with Aquatic guidelines as
directed above.
_______________________________________
Patient Signature
____________________________
Date
_________________________________
Therapist Signature
________________________
Date
PATIENT COMPLIANCE POLICY
Synergy Therapies
Aquatic, Rehab, and Sports Clinic
The staff at Synergy Therapies is pleased you have chosen to have your therapy with us.
We welcome the opportunity to provide you excellent care to assist you in the healing process,
and we will do our best to meet your expectations.
In return we ask that you agree to the following:
1. Make therapy a priority:
a. Scheduling appointments that coordinate your schedule with our availability is
often a very difficult task, so we ask you to please remain flexible so that we may
accommodate your rehabilitative needs.
b. Comply with the recommendations and home exercise program provided by your
therapist.
2. Inform your therapist in advance of when you return to your referring physician for follow
up so that reports may be sent in a timely manner.
3. Understand that it is our goal to keep you with one (1) to three (3) therapists during your
treatment duration. Schedule conflicts, vacations, etc. dictate treatment availability, so
please be flexible.
4. If you need to reschedule an appointment, please call (816) 795-8944 at your earliest
convenience so that, if needed, another patient may be treated.
5. You may be discharged if:
a. Scheduled appointments are routinely cancelled
b. You “no show” for two (2) consecutive appointments without calling
c. You cancel three (3) or more appointments with reason at the discretion of the
therapist
Please ask your therapist if you have any questions. Thank you.
I have read and agree to the above.
___________________________________
Signature
____________________________
Date