Patient Name: Male Female Married Divorced Widowed Single. SSN: Date of birth: Address: Phone: (home) (cell) (other) Emergency contact name:

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1 Patient Information: Patient : Male Female Married Divorced Widowed Single SSN: of birth: Address: Phone: (home) (cell) (other) Emergency contact name: Relationship to patient: Emergency contact phone: If the Patient is under 18: Parent/guardian s name Parent/guardian s DOB* Parent/guardian s SSN* *We need this information to bill insurance. I would like appointment reminders sent to me via: Please list . Text message: Please list phone number & carrier (Verizon, T-Mobile, Sprint, etc). The reminder cannot be sent without the carrier information. I would not like appointment reminders. Insurance Authorization: I hereby consent to such medical procedures as may be rendered by Idaho Physical Therapy and authorize for all insurance benefits (including Medicare and/or Medicaid, if applicable) to be paid directly to Idaho Physical Therapy on my behalf. I also assume financial responsibility for the balance of charges not included in my insurance coverage. I authorize Idaho Physical Therapy to release to my insurance company and its agents any information needed to determine the benefits or the benefits payable for related services. Patient Signature Parent Signature (if Patient is under 18)

2 Patient Medical History Questionnaire Circle Yes or No as applicable. Have you ever had: Cardiac Pacemaker YES NO Kidney Disease YES NO Heart Attack YES NO Seizures YES NO Angina/Chest Pains YES NO High Blood Pressure YES NO Emphysema/COPD YES NO Low Blood Pressure YES NO Cancer YES NO Shortness of Breath YES NO Stroke YES NO Chronic/Frequent Cough YES NO Diabetes YES NO Depression YES NO Blackouts YES NO Indigestion/Ulcers YES NO Blurred/Double Vision YES NO Tuberculosis YES NO Nervousness/Anxiety YES NO Blood Clot YES NO Asthma YES NO Allergies YES NO Hernia YES NO Gout YES NO Unexplained Weight Loss/Gain YES NO Are you now pregnant or do you Liver Disease YES NO suspect you might be? YES NO For all conditions in which a Yes was indicated above, please give dates and details below: Do you have any other medical problems which are not listed here (including any recent surgeries)? List current medications and dosages (include over-the-counter meds & vitamins): Your Height Your Weight Do you consume alcohol? Yes No If Yes, how many drinks per day/week? Do you smoke? Yes No If Yes, how many packs per day/week? Is the injury/condition you are seeking treatment for today due to an accident? YES NO Is this injury/condition part of a workers comp claim? YES NO Is this injury/condition due to a motor vehicle accident? YES NO - If YES, please list the state in which the accident took place: of Accident (if applicable): I certify to the best of my knowledge that the above answers are true and correct. Patient Signature

3 PAYMENT POLICY 1. All patient co-payments are due in full at time of service. 2. Idaho Physical Therapy will gladly bill your insurance company for you according to the services and procedures performed during your visits; however, please remember that it is your responsibility to know exactly what your insurance plan covers. 3. Patients who are not covered by an insurance company must pay in full at the time of service. We have self-pay options available; please ask for details. 4. If payment arrangements are necessary, we will be happy to work out a payment schedule with you to clear your account. Monthly payments are required to keep accounts open and out of collection status. Please contact our billing department if you have any questions. 5. Idaho Physical Therapy will submit bills to your insurance company for services rendered. After this, the bill is considered your responsibility, regardless of whether your insurance company makes payment. 6. If you are seeking treatment as part of a workers compensation claim, understand that if your claim is denied, you will become responsible for the charges accrued during your time of service. 7. If you have any questions regarding these policies, please contact us before services begin. 8. This form is informational in nature only and is intended to communicate to you our payment policies. These policies do not change in the event that you refuse to sign this form. ATTENDANCE POLICY Please carefully review the following guidelines concerning your scheduled visits here at Idaho Physical Therapy. The following information has direct implications on the success of your treatment. A 24 hour notice either by phone or personal visit is expected when canceling a scheduled appointment. After-hours voic s are also acceptable as long as they are at least 24 hours in advance. You will be charged $10 for each appointment cancelled without 24 hours notice. A charge of $15 will be assessed to persons who simply fail to show up and who do not call at any time to inform the office of their inability to attend their appointment. This charge is to be paid by you, not your insurance company, at the next scheduled visit. Patients will be given one grace no show/cancellation, after which fees will be charged. Patients whose accounts have been on hold (meaning you are waiting to come back to therapy for any reason) for more than 30 days will be discharged. NOTICE OF PRIVACY CONSENT FORM I have been presented with a copy of Idaho Physical Therapy s Notice of Privacy Practices, which explains: How this office will use and disclose my protected health information My privacy rights in regard to my protected health information This office s obligations concerning the use and disclosure of my protected health information I understand that the Notice of Privacy Practices may be revised from time to time and that I am entitled to receive a copy of any revised Notice of Privacy Practices upon request. I also understand that if I have any questions or complaints, I may contact this office. I have read and understand all the terms stated above. Guarantor or Patient (please print) Guarantor or Patient Signature

4 Due to HIPAA regulations, we cannot share your protected health information (PHI) with anyone without your consent. However, many times our patients will need the help of family, friends, and/or caregivers during their recovery. If you wish for anyone else to be able to speak with us about your medical information (including appointment times and financial information), please list them below. You may revoke this authorization in writing at any time, except where we have already released your information based on your prior authorization. OR if you would not like us to share your information with anyone at all, please check the box at the bottom of the page. I do not want my medical information shared with anyone except where I specifically give permission on a case by case basis (i.e. records release to doctors, lawyers, etc.) Patient Patient Signature (or Guardian Signature if Patient is under 18)

5 MOTOR VEHICLE ACCIDENT POLICY (Note: This only applies if therapy is required because of a motor vehicle accident.) of auto accident: State where auto accident occurred: Due to delayed payments from third party insurances and lengthy legal settlements, Idaho Physical Therapy does not accept third party billing. If YOUR health insurance or auto insurance will not pay for your treatment, you will be responsible for the bill. Upon your discharge, payment becomes due in full. If necessary, you may make arrangements for regular monthly payments with our billing department. Payments must be made every month in order to keep your account active and out of collection status. If you fail to adhere to these policies, your account will be referred to an outside collection agency. This will apply even if you have an attorney. By signing this policy, you are agreeing to these conditions. Patient (please print) Patient Signature