Download PHYSICAL THERAPY ENROLLMENT FORMS Name: DOB: Address

PHYSICAL THERAPY ENROLLMENT FORMS
Name:
DOB:
Address:
City:
State:
Home Phone #:
Work Phone #:
Email:
Employer:
Marital Status:
Student?: yes/no
o
Zip Code:
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? Yes/No If so, when?__________
Is it the same problem? Yes/No
Purpose of your Visit (Problem): __________________________________________________________
Do you have a prescription? Yes/No
Post Op? Yes/NO
Referring Physician: _________________Phone:_______________
Surgery Date: ___________________
Have you had physical therapy this year? Yes/No If so, how many visits were used?_________________
Is this injury a work related or auto related accident?
Insured’s Information
Yes/No
O Check here if insurance card already supplied to office
Name of Insured:
Relationship to insured:
D.O.B
________
Insurance Carrier:
Phone #:
________
Member ID:______________________Group #:________________Group Name:___________________
Workman’s Compensation/Motor Vehicle Insurance (complete if work or auto related): ONLY In-network
Date of Accident: _______________Policy/Claim ID:________________Auth/Precert #:______________
Carrier Name:___________________Phone:_________________________________________________
Address:_______________________City:_____________________State:_________________Zip:______
Claims Adjuster/Contact Person’s Name:________________________________Phone:_______________
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 Notice 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 Signature
Date
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. Not 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.
Signature:
Date:
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.
Signature:
Date:
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 #
Exp. Date:
Signature:
Date:
OFFICE USE ONLY: Deductible amount expected when services are rendered: $___________________
Co-insurance/Co-Payment expected when services are rendered: $___________________
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 ______________
no pain =
0
Circle a number from 0-10 to indicate the severity of your pain
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: O Improving
O Stable
O Worse
Have you had previous similar occurrences of these symptoms?
O Yes
What, if any, treatment have you had for this problem? O Physical therapy
Did this treatment help? O Yes O No Explain:
Have you had any special tests (MRI, x-rays, etc) and what were the results?
O No If yes, describe:
O Chiropractic
O Acupuncture
O Other ________________
Medical History
Have you been discharged from a hospital or skilled nursing facility in the last 30 days? O Yes O No If yes, date of discharge:
List any past surgeries you have had:
List all medications you are presently taking:
Are you pregnant? O Yes O No If yes, how many months?
Have you experience or are you currently experiencing? If yes, please circle
Allergies
Diabetes
Kidney Disease
Pneumonia
Anemia
Difficulty Walking
Low Back Pain
Rheumatoid Arthritis
Angina or Chest Pain
Difficulty Swallowing
Neck Pain
Shortness of Breath
Arthritis or pain in a joint
Emphysema
Obesity
Stomach Problems
Asthma
Fracture
Open Skin Sores
Stroke
Cancer
Headaches
Osteoporosis
Weight change
Chronic Bronchitis
Heart Disease
Pacemaker
Urinary Tract Infection
Circulatory Problems
Hepatitis
Pain with coughing
Mental Disorders
Depression
High Blood Pressure
or sneezing
Vestibular (Inner Ear)
Other:
Signature:
Date:
Documentation and Verification of Medication
Medications (prescription and over the counter), supplements, vitamins; at Initial Evaluation
Medication Name
Dose (mg)
Quantity/Frequency
Signature:
Initial/Date if same
at re-evaluation
Initial/Date if same
at re-evaluation
Date:
Changes at Re-evaluation
Medication Name
Signature:
Dose (mg)
Quantity/Frequency
Date/Patient Initials
Date:
Initial/Date if same at
Re-evaluation
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.
Medicare program provisions are contained in relevant laws, regulations, and rulings.
Patient Name:
Signature:
Form No. CMS-20007 (January 2003)
Date:
The official
Medicare Screening Form
A. Falls: Risk Assessment - For patients > 65 years of age; Eval or Re-Eval
1.
2.
3.
4.
Have you fallen in the last 12 months? Yes / No
How many times have you fallen? ______ If 2 or more, please complete a falls risk assessment.
Did your fall(s) result in injury?
Yes/ No If yes, please complete a falls risk assessment.
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. Yes / No
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 Reeval
1. Pain was assessed on evaluation or on re-evaluation for intensity, quality and location AND a follow-up plan was
documented. Yes/No
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. Yes / No
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. Yes / No
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 Not 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 Signature:
Date:
POPT-1000
Notice 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 protected 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
practices, 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 concern to the same address. You will not be penalized or otherwise retaliated
against for filing a complaint.