FOOTHILLS SPORTS MEDICINE AND REHABILITATION. PATIENT REGISTRATION FORM Please Print
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1 FOOTHILLS SPORTS MEDICINE AND REHABILITATION PATIENT REGISTRATION FORM Please Print Patient Name: Patient Social #: Gender: [ ] Male [ ] Female Birth Date: Age: Address: City, State, Zip: Home Phone: Cell Phone: Work Phone: Authorization to leave voice message, please initial Parent/Guardian: Relationship to Patient: Parent/Guardian Social #: Parent/Guardian Birth Date: Referring Physician: Primary Physician: Emergency Contact: Relationship/Phone: Employer/School/Team Name: How did you hear of Foothills Sports Medicine and Rehabilitation? [ ] Referred by Doctor [ ] Friend or Family [ ] Social Media/Online [ ] Other: Insurance Information (To be completed even if insurance card on file) Primary Insurance Secondary Insurance Insurance Co Name: Insurance Co Name: Policy Holder: Policy Holder: Policy Holder Birth Date: Policy Holder Birth Date: Relationship to Patient: Relationship to Patient: AUTHORIZATION TO RELEASE PATIENT INFORMATION: I hereby authorize Foothills Sports Medicine and Rehabilitation to release any personal health information (PHI) required in the course of my examination or treatment to the above stated insurance company, or their affiliates. Signed (Patient or guardian) Date AUTHORIZATION TO PAY: I hereby authorize insurance payment directly to Foothills Sports Medicine and Rehabilitation, Billing Department, S. Mountain Pkwy. Suite 112, Phoenix, AZ for medical services rendered. I understand that I am financially responsible for the charges not covered by my insurance. In the event of default, I promise to pay collection costs and reasonable fees as may be required to obtain collection of this account. Signed (Patient or guardian) Date FOOTHILLS SPORTS MEDICINE AND REHABILITATION BILLING DEPARTMENT S. MOUNTAIN PKWY. SUITE 112, PHOENIX, AZ 85044
2 CANCELLATION / NO SHOW POLICY Due to the nature of physical therapy, your progress and full recovery are dependent on both our experienced physical therapists, and your active participation and commitment to your appointments. Our policy is as follows: CANCELLATION If you need to cancel your appointment, please contact Foothills Sports Medicine at least one day prior to your appointment. If you call to cancel your appointment on the same day as your appointment, a $25.00 Cancellation Fee will be assessed. The fee will be due on your next scheduled date of service. An appointment rescheduled for the same day or within the same week is not considered a cancellation. NO SHOW If you have a scheduled appointment and do not show, a $25.00 No Show Fee will be assessed. These fees will be WAIVED if you reschedule the missed appointment WITHIN the week that you cancel. Signature: Date:
3 ELECTRONIC COMMUNICATION CONSENT Patient Name: Cell Phone: Appointment Reminders Complete this form and sign below to give your permission for Foothills Sports Medicine to provide automatic appointment reminder service by or by cell phone text message. OPTION: Foothills Sports Medicine may send messages to confirm my upcoming appointments. TEXT OPTION: Foothills Sports Medicine may send cell phone text messages* to confirm my upcoming appointments. Please indicate your cell phone carrier: *Normal text messaging rates may apply. ALLTel AT&T Boost Mobile Cingular Cricket Wireless Metrocell MetroPCS Nextel Quest Sprint PCS T-Mobile US Cellular Verizon Virgin Mobile Text Message Surveys In an effort to provide an outstanding customer experience and to provide the highest possible quality of care, Foothills Sports Medicine Physical Therapy may send you text messages about your visit and other educational content related to your treatment. You may opt-out at any time by replying STOP to any text you receive. (initial) Join our Mailing List Stay connected with all of the latest updates from Foothills Sports Medicine Physical Therapy. By providing your address, you agree to receive periodic updates from Foothills Sports Medicine Physical Therapy. You may opt-out at any time by unsubscribing via the link at the bottom of every . (initial) Signature: Date:
4 FOOTHILLS SPORTS MEDICINE AND REHABILITATION NOTICE OF PATIENT INFORMATION PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION, INCLUDING HOUSE BILL PLEASE REVIEW IT CAREFULLY. FOOTHILLS SPORTS MEDICINE & REHABILITATION, INC. S LEGAL DUTY Foothills Sports Medicine & Rehabilitation, Inc. is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow these practices that are described herein. USES AND DISCLOSURES OF HEALTH INFORMATION Foothills Sports Medicine & Rehabilitation, Inc. uses your personal health information primarily for treatment; obtaining payment of treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example, Foothills Sports Medicine & Rehabilitation, Inc. may use your personal health information to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you. Foothills Sports Medicine & Rehabilitation, Inc. may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law. In any other situation, Foothills Sports Medicine & Rehabilitation, Inc. s policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time. Foothills Sports Medicine & Rehabilitation, Inc. may change its policy at any time. When changes are made, a new Notice of Information Practices will be posted in the clinic and will be provided to you on your next visit. You may also request an updated copy of our Notice of Information Practices at any time. PATIENT S INDIVIDUAL RIGHTS You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate information or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes. You may also request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. Foothills Sports Medicine and Rehabilitation will consider all such requests on a case by case basis, but the practice is not legally required to accept them.
5 CONCERNS AND COMPLAINTS If you are concerned that Foothills Sports Medicine & Rehabilitation, Inc. may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact the following person: Cheri Anguis You may also file a complaint with the Department of Health and Human Services via mail, fax, , or the OCR Complaint Portal. Additional information can also be found on their website at You will not be retaliated against for filing a complaint. HOUSE BILL 2045 Effective December 31, 2013, in accordance with the Arizona House Bill 2045 which requires healthcare providers who are owners or employees of a legal entity with three or more licensed healthcare providers to post their direct pay prices for their 25 most commonly provided services online or make them available upon request. The bill specifies how services are to be identified, how often the list is to be updated and the timeframe from which the list is to be determined. HB 2045 also requires healthcare providers to obtain a person s signature on a notice before accepting direct payment from that person if the healthcare provider is contracted as a network provider for a healthcare system in which the person is an enrollee. For more information about House Bill 2045, please visit the website of the Arizona State Legislature, azleg.gov. You may search for the bill using their Bill Number Search. All patients or their guardians must read and acknowledge the following guidelines. MEMBER DIRECT PAYMENT NOTIFICATION PROVIDER Arizona state constitution permits you to pay a healthcare provider directly for health care services. Before you make any agreement to do so, please read the following important information. If you have active health insurance coverage and your healthcare provider is contracting with your health insurance provider, the following guidelines apply: 1. You may not be required to pay the healthcare provider directly for the services covered by your health insurance plan, except for the cost-share amounts that you are obligated to pay under your plan; such as co-payments, co-insurance, and deductible amounts. 2. Your healthcare provider s agreement with your health insurance plan may prevent the healthcare provider from billing you for the difference between the healthcare providers billed charges and the amount allowed by your health insurance plan for covered services. 3. If you pay directly for health care service(s), your healthcare provider is not responsible for submitting claim documentation to your health insurance plan. Before paying your claims, your health insurance plan may require you to provide information and submit documentation necessary to determine whether the services are covered under your health insurance plan. 4. If you do not pay directly for health care service(s), your healthcare provider may be responsible for submitting claim documentation to your health insurance plan for the health care service(s).
6 PATIENT INFORMATION ACKNOWLEDGEMENT FORM I have read and fully understand Foothills Sports Medicine & Rehabilitation, Inc. s Notice of Information Practices. I understand that Foothills Sports Medicine & Rehabilitation, Inc. may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment, and administrative operations if I notify the practice. I also understand that Foothills Sports Medicine & Rehabilitation, Inc. will consider requests for restriction on a case by case basis, but does not have to agree to request for restrictions. I hereby consent to the use and disclosure of my personal health information for purposes as noted in Foothills Sports Medicine & Rehabilitation, Inc. s Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time. Your signature below acknowledges that you received House Bill 2045 notice before paying this provider for healthcare service(s). Patient Name: Signature of responsible party: Printed Name of signer: Date: DESIGNATED INDIVIDUALS AUTHORIZATION FORM I hereby authorize one or all of the designated parties listed below to request and receive the release of any protected health information regarding my treatment, payment or administrative operations related to treatment and payment. I understand that the identity of designated parties must be verified before the release of any information. Authorized Designees: Name: Relationship: Phone: Name: Relationship: Phone: Name: Relationship: Phone: Patient Name: Signature of responsible party: Printed Name of signer: Date:
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NORTH RALEIGH PSYCHIATRY, P.A. PATIENT REGISTRATION SHEET Today s Date: Please print all information. Thank you. Patient Name: Nickname: LAST FIRST MI Patient Address: City: State: Zip: Patient Sex: M
WOMEN S PREMIER OBGYN REGISTRATION FORM
WOMEN S PREMIER OBGYN REGISTRATION FORM Today s date: PCP: PATIENT INFORMATION Patient s last name: First: Middle: q Miss q Ms. Marital status (circle one) Single / Married / Divorced / Sep / Widow Is
Agape Physical Therapy and Sports Rehabilitation. Patient Name: Birthdate Social Sec.
INSURANCE INFORMATION As a courtesy to our patients, we will verify and file your insurance claim; HOWEVER, we cannot guarantee payment by your insurance company. We strongly suggest that you read your
Child s Name Date of Birth. Address. City State Zip. Father s Name Phone (home) Phone (cell) Address. City State Zip.
Client Information Child s Name Date of Birth Address City State Zip Father s Name Phone (home) Phone (cell) Address City State Zip Email Father s Employer Mother s Name Phone (home) Phone (cell) Address
Please print and complete all the enclosed forms and bring them to your first appointment.
Dear Valued Patient, Thank you for requesting an appointment in our office. Please print and complete all the enclosed forms and bring them to your first appointment. When you arrive at our office for
Name: Employer: Phone: Phone: Social Security: Occupation: Previous Therapy: Primary Doctor: Phone number: Fax Number: Referring Doctor:
PATIENT INTAKE FORM Patient Information Hands On Physical Therapy Please fill this form out completely. Thank You! Name: Employer: Address: City/State/Zip: Address: City/State/Zip: Phone: Phone: Date of
Authorization to Release Health Information
Authorization to Release Health Information Patient Information: Name of Patient Date of Birth Address City, State, Zip Phone At my request, may release the following information: (Name of the entity)
Best Time To Call. Referring Physician:
Page: 1/6 EXCEL PHYSICAL THERAPY PATIENT DATA SHEET DO NOT EMAIL The electronic form is provided for your convenience. With respect to responding to this form, please do not send via email. Please populate,
6677 W. Thunderbird F N. Hayden Rd. H-100 Glendale, Az Scottsdale, Az
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PATIENT INFORMATION. Child s Name: DOB: Address: Phone: Zip: School: Emergency Contact: Phone: Relationship to Patient:
PATIENT INFORMATION Child s Name: DOB: Address: Phone: Zip: School: Father s Name: Occupation: Phone: (work) Email Address: Mother s Name: Occupation: Phone: (work) Email Address: DOB: Social Security
Child s Name: Gender: M or F Last First MI. Date Of Birth: - - ADDRESS: CITY: STATE ZIP: REFERRING SOURCE. Physician Name Last First MI
PATIENT INFORMATION PATIENT INTAKE FORM DATE: PT/OT/ST Child s Name: Gender: M or F Last First MI Date Of Birth: - - SS# - - ADDRESS: CITY: STATE ZIP: REFERRING SOURCE Physician Name Last First MI Phone:
Secondary Insurance Information: Name of Insured: Relationship to Insured: Self Spouse Child Other
PATIENT REGISTRATION First Name: Last Name: Middle: Preferred Name: Patient is: Responsible Party Policy Holder Responsible Party: ( if someone other than the patient ) First Name: Last Name: Middle Initial:
New Client Information Sheet
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Patient name: LAST FIRST MIDDLE. Address: Responsible Party SS#: Required If patient a minor and/or full-time student. Employer: Occupation:
PATIENT Information SHEET ACCT # PT Patient name: LAST FIRST MIDDLE Date of Birth: Age: (please circle :) Female Male Address: Responsible Party SS#: Required If patient a minor and/or full-time student
Minor Registration Forms Please Print Legibly. Demographics. *Patient Last Name: *First Name: Middle Initial:
*Indicates Required Fields Minor Registration Forms Please Print Legibly Demographics *Patient Last Name: *First Name: Middle Initial: *Date of Birth: / / *Gender: Male Female *Prefix: Mr. Miss Ms. Mrs.
JOEL D. FOSTER DPM, PC AUTHORIZATION TO RELEASE MEDICAL BENEFITS
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PSYCHIATRY AND FAMILY COUNSELING, LLP Leominster Westborough Worcester
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MANUAL OF UNIVERSITY POLICIES PROCEDURES AND GUIDELINES. Applies to: faculty staff students student employees visitors contractors
Number: Page 1 of 12-3 14 Applies to: faculty staff students student employees visitors contractors Effective Date of This Revision: September 23, 2013 Contact for More Information: Chief Privacy Officer
New Patient Information Form
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NOTICE OF $30 FEE FOR NEW EYEGLASS PRESCRIPTIONS
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