EMERGENCY CONTACT Name of relative/friend not living with you. Home Phone Cell INSURANCE

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1 DATE PATIENT INFORMATION Name Date of Birth Home# Work# Cell# Do you receive text messages? Address City State Zip SS# Sex Marital Status Employer If Student, what school? Spouse s Name Who may we thank for referring you to our office? If a MINOR, who is the person FINANCIALLY RESPONSIBLE for this patient? The responsibility for account balances remains with parent and/or legal guardian who accompanied the patient to our office. Name Relationship to Patient Date of Birth Home# Work# Cell# Do you receive text messages? Address City State Zip SS# Sex Marital Status Spouse s Name Employer EMERGENCY CONTACT Name of relative/friend not living with you _ Home Phone Cell INSURANCE PRIMARY MEDICAL INSURANCE INFORMATION (Person Insurance is through) Name of Insurance Company Name of Cardholder (Subscriber) Date of Birth Relationship to patient Subscriber s SS# Phone# Employer Address Policy # Group # Ins. Co Address SECONDARY MEDICAL INSURANCE INFORMATION (Person Insurance is through) Name of Insurance Company Name of Cardholder (Subscriber) Date of Birth Relationship to patient Subscriber s SS# Phone# Employer Address Policy # Group # Ins. Co Address

2 Release of Information: I agree to allow Semmes Physical Therapy to: Provide information from my medical record to persons involved in my medical care. Release medical information necessary to obtain payment of any benefits available for services rendered. Obtain information from others who have provided medical care to me and/or are responsible for the payment of all or part of my bills when this information is needed in order to treat, bill, and/or receive payment. Give the Social Security Administration or its fiscal intermediary s information necessary to process claims and agree that the information given in applying for benefits under Medicare or Medicaid services are complete and accurate Non-Discrimination: Admission to our clinic is non-discriminatory for services rendered, regardless of race, color, national origin, disability, or age. All clients who come to our clinic for services are protected against discrimination assured by Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of School Affiliations: Semmes Physical Therapy will adhere to all set AHSAA standard involving athletes and the coordination of their care with the representatives of their schools and/or athletic affiliations. Refer to the participant agreement, consent, and release form kept on file through your school and the board of the AHSAA. This consent and authorization specifically includes but is not limited to: Psychological, psychiatric, alcohol, drug abuse, and HIV/AIDS information. Workman s Comp: All clients filing an open and approved Workman s Comp claim are excluded from any charges incurred by Semmes Physical Therapy, LLC. Documentation of any missed appointment will be forwarded to your adjuster, case manager, and primary physician which can jeopardize your claim. I agree that the information given to Semmes Physical Therapy are complete and accurate and that Semmes Physical Therapy may give intermediary s information necessary to process claims. Motor Vehicle Accident (MVA): I understand that in the event of a MVA, Semmes Physical Therapy, will file my primary insurance carrier and will not file any third party liability company. I understand that Semmes Physical Therapy will assist me in filing my third party auto insurance claim by providing financial statements. A letter of guarantee from the representing attorney or responsible insurance party must be on file, but I understand that this does NOT release patient from responsibility. Financial Agreement: I understand that once my diagnosis has been established and a plan of treatment recommended, the fees involved and methods of payment will be discussed with me and a financial agreement established. I authorize the direct payment of any benefits available to be released to Semmes Physical Therapy for services rendered. I, the undersigned, accept the fee(s) charged as a legal and lawful debt. I understand the fee(s) charged are due at the time of service. Should it become necessary to forward my account for collection, I agree to pay all monies due, including a 33.33% collection fee, Attorney Fees, and/or Court Costs, if such be necessary. I waive, now and forever, my right of exemption under the laws of the Constitution of the State of Alabama and any other state. I, the undersigned, give Semmes Physical Therapy, LLC, its employees and/or agents express prior consent to contact me at any/all phone numbers, including cell phone numbers (by phone call or text message), for the purpose of treatment, insurance and/or payment. Consent for Treatment: I, the undersigned, understand that my treatment is under the direction of my referring physician and hereby give authorization for the performance of such rehabilitation procedures as permitted by Alabama Statutes under the appropriate scope of practice are, in the judgment of my Therapist, deemed necessary.

3 HEALTH HISTORY Patient s Name Date of Birth Please complete the following information so that we may provide safe and effective care for you. PLEASE LIST YOUR: MEDICATIONS: CHECK IF NONE DIAGNOSIS/DISEASES: CHECK IF NONE _ OPERATIONS:(Names/Dates) CHECK IF NONE _ ALLERGIES: CHECK IF NONE HOSPITAL ADMISSIONS: CHECK IF NONE (Date/Reason) HAVE YOU EVER HAD: YES NO *If YES, CIRCLE WHAT APPLIES YES NO *If YES, CIRCLE WHAT APPLIES Angina, heart attack, chest pains, heart disease? Rheumatic or Scarlet fever? Heart Murmur or heart valve disorder or artificial valve? Congenital Heart Defect? Enlarged or Failing Heart? Abnormal or irregular heartbeat, palpitations, pacemaker? Implants anywhere in your body? (heart valve, hip, knee) High Blood Pressure? Asthma, shortness of breath or emphysema? Difficulty breathing at rest, with mild exertion or lying down? TB, pneumonia, chronic cough, chronic bronchitis, COPD? Diabetes? Cortisone or steroids? Anemia or sickle cell disease or trait? Anticoagulants (blood thinners) or frequent aspirin? Excessive or abnormal bleeding or bruising? Stroke or paralysis? Mental or physical limitations? Stomach or intestinal disease or colitis, hernia, reflux? Hepatitis, jaundice, cirrhosis, or liver disease? Recent unexplained weight loss or gain? Kidney or bladder disorder, dialysis? Disorders of the immune system? Venereal Disease, AIDS or HIV infection, ARC, herpes? Bone or joint disorder, injury or arthritis or muscle disorder? Eye disorder, glasses, contacts, glaucoma, lens implant? Ear disorder? TMJ (jaw joint) disorder, jaw pop, click, or lock? Head, ear, face, neck ache or pain, grind or clench teeth? Blood Transfusions? Why & Where? Infectious or contagious disease? LIST _ Tumors, cancer, chemotherapy or radiation treatment? Diet, energy or herbal pills or medication? Medications for osteoporosis, bone disease or cancer? Do you prefer private treatment following evaluation? Epilepsy, seizures, or convulsions? Skin Disorder? Fainting, dizziness or vertigo? Please continue on reverse side Rev June 2017

4 Are You: Height: Weight: YES NO Pregnant Now? Have you received any speech or physical therapy this year? No Yes, how many visits? Are you currently receiving any type of home health? NO YES - Name of Company Do You Use: YES NO Alcohol? Tobacco? Do you have plans for future orthopedic surgery this calendar year? NO YES Do you live alone? YES NO Do you have frequent falls? YES NO IS THERE OTHER INFORMATION THAT YOU WOULD LIKE US TO KNOW? YES NO REASON FOR TODAY S VISIT Date of Injury, accident or onset of pain PATIENT S PHYSICIAN Date of next appointment with your referring physician: To the best of my knowledge, the above information is complete, true and accurate.

5 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. (Please Print Name) (Signature) (Date) FOR OFFICE USE ONLY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communication barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify)