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1 Office Use Only: Date of Intake: Appt date/time: Therapist: Insurance: Full Name: DOB: Sex: M F SSN: Page A-1 of 5 Billing Home Cell Work Appointment reminder: Voice Text - Which #: Emergency Contact: Relationship: For what are you seeking treatment? Due to accident surgery neither? Date of accident/surgery: Referring physician: PCP: How much pain do you have with this condition? Circle the area of pain and indicate level of pain below: Pain Scale is 0-10: 0 = none / 10 = severe intermittent / constant Pain is: Primary Insurance Primary Insurance: Name: Relationship to : DOB: ID #: Group #: Secondary Insurance Secondary Insurance: Name: Relationship to : DOB: ID #: Group #:
2 Page A-2 of 5 Assignment of Medical Insurance Benefits Thank you for choosing We will work with you and your insurance carrier to submit claims but would like you to understand our office policy regarding insurance assignment. Payment is expected at the time of service unless we accept assignment from your insurance carrier or previous payment arrangements have been made. For our office to accept insurance assignment, we ask that you read and sign the following: You acknowledge that it is your responsibility to: 1. Provide complete, current information on medical insurance coverage for yourself (or if the patient is under 18), including presenting a valid insurance card at the time of service. 2. Pay applicable co-payment at the time of service. A minimum per-visit charge may be asked for high deductibles that have not yet been met. 3. Present a valid referral or authorization number for all services (if required by your insurance company). Your primary care physician or referring specialist can help you if needed. 4. Inform us if the patient s need for medical services is due to a motor vehicle, worker s compensation or other accident. 5. Make payment within 30 days on any balance on your account for amounts due such as deductibles, coinsurance, co-payments or non-covered services. 6. Verify that this provider is in network with your particular insurance plan under your insurance carrier. You are ultimately responsible to pay the medical bill if your insurance company does not honor the assignment of benefits in whole or in part. Your signature below indicates: 1. You understand and accept our policy of assignment of insurance benefits. 2. You attest to the accuracy and completeness of the medical insurance coverage information. 3. You authorize this office to release medical information necessary to process your claims and appeals. 4. You authorize payment of medical benefits to
3 Page A-3 of 5 Financial Policy As a courtesy to you, we will verify your coverage and bill your insurance company on your behalf. Although you agree and allow us to bill your insurance company, the verification is not a guarantee of your insurance coverage or that your insurance will pay. However, you are ultimately responsible for payment of your bill. Your insurance policy is a contract between you and your insurance company. Our company will not become involved in disputes between you and your insurance company regarding deductibles or co-payments. Co-pays and deductibles are due at the time of service. A bounced check will result in a minimum fee of $ I agree to pay any charge which is denied or not paid by my insurance; this includes, but is not limited to deductibles, coinsurance and co-pays. I am responsible to pay my portion on the date services are rendered. I will be responsible for any cost incurred on overdue balances, including but not limited to late fees, interest fees (18% APR), legal fees and collection agency fees. Insurance companies have days to process any claims so we may not know what your portion of the bill may be until the claim has been processed. Please notify this office if special financial arrangements are necessary. Only written financial agreements will be honored; no verbal or implied agreements accepted. Any billing questions need to be directed to the PT-MD Kinect LLC and Partners in Health Healing Center s billing company: Flatirons Practice Management My benefits PER VISIT are: In-Network Co-pay: $ * Visit Limitations: Deductible: $ * Deductible Met: $ Insurance Pays: % * My Co-insurance: % After Deductible? No Yes You are responsible for payment of your deductible, co-insurance, co-pay and understanding your insurance benefits. Due to various insurance benefit limitations, it is important to list how many previous visits you ve attended this year of Physical Therapy: Release of Information: I authorize and P3 Network to release any information acquired in connection with my therapy service(s), including but not limited to diagnosis, clinical records, to myself, my insurance(s), physician(s) and. Assignment of Benefits: I hereby authorize payment to be made directly to and the P3 Network which includes PT-MD Kinect LLC, Matthew D. Pouliot DO, Partners in Health Healing Center, and Heather L. Fliege MD. Authorization for Treatment: I authorize the treatment of the patient or minor patient named below, and I hereby agree to be responsible for all charges for services rendered. I have had the opportunity to review the Notice of Health Information Practices Privacy Notice (HIPAA privacy act) prior to signing this consent. If you are unable to keep your appointment, you must notify us 24 hours in advance. Failure to do so will result in a $45.00 broken appointment charge. reserves the right to discharge patients if there are 3 or more no-shows or cancellations within a month or in a row.
4 Page A-4 of 5 Thank you for choosing A Member of the P3 Network PT-MD Kinect LLC and Partners in Health Healing Center Below is some information you may find helpful regarding your benefits and your responsibilities: Your services are being billed under the P3 contract. This means that billing will reflect the following provider and network facility names: o PT-MD Kinect LLC o Matthew D. Pouliot DO o Partners in Health Healing Center o Heather L. Fliege MD Your insurance company told us they cover visits per calendar, plan or policy year. If you have received physical therapy earlier in the year, those visits will count toward this maximum. Remember, your prescription from your doctor is a suggestion; however, insurance co-dictates the total number of visits allowed depending upon your injury and expected progress. If you have any questions about your insurance coverage or your policy, please contact your insurance company. Importance of Paperwork and Re-evaluations: Evaluations, re-evaluations, special tests and thorough documentation allows us to identify the best treatment to assist you in a complete recovery. These re-evaluations and progress surveys are used to make adjustments in your treatment program to assure you of quality care that results in a quick and complete recovery. Your assistance in filling out these forms and progress surveys is appreciated. Scheduling: Please schedule as much in advance as possible so we can provide you with convenient appointment times. Also, try to schedule with the same therapist (but not more than two therapists if necessary) to allow consistency with your treatment so we may give you quality care. Please be aware that we are here to serve you; however, if you will not be able to be here, kindly give us a 24- hour notice if you have to cancel your appointment. All missed appointments or no shows will be charged a $45 fee to the patient. We have reserved an allotted time for you which is now lost. Billing: You have signed our Financial Policy that will allow the P3 network to bill your insurance company. Any billing questions need to be directed to the PT-MD Kinect LLC and Partners in Health Healing Center (P3 Network) billing company: Flatirons Practice Management ( ). Payment for co-pays, deductibles and supplies are due at the time of service. Payment plans are available and can be set up with a billing representative. Only written financial agreements will be honored; no verbal or implied agreements are accepted. You are responsible for any portion of your bill which is denied or not paid by your insurance. This includes, but is not limited to: deductible, coinsurance and co-pays. Insurance has days to process any claims, which means we may not know what your portion of the bill may be until the claim has been processed. Supply Policy: Various supplies may be very helpful in speeding your recovery. Supplies must be paid for the same day they are taken home. If you need to return a supply, we ask that you do so within 10 business days with the original packaging and in new, resalable condition. You must have a receipt. No returns on special orders or custom items.
5 Page A-5 of 5 Privacy Notice: I, the below-named patient, are entitled to certain privacy rights regarding protected health information according to the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I understand that during the course of treatment, AGPT will collect personal information about me that is necessary for treatment. AGPT will treat this information as confidential and realizes the importance of protecting that information. A complete copy of our HIPPA Privacy Practices is available upon request. I authorize AGPT to leave messages on my voic regarding appointments and other personal information related to my care. I authorize AGPT to speak with regarding personal information related to my care (this can be a spouse, family member or trusted confidant that you give permission to relay messages or communicate with us for you). DO NOT leave personal/confidential information on my voic , only tell me in person or on the phone. I have read the above information and by signing below consent to financial responsibilities, release of information, assignment
Advantage Physical Therapy Patient Registration
Appointment Date/Time: Therapist: Advantage Physical Therapy Patient Registration ****Please note ALL patients are required to have a prescription for Physical Therapy from a referring Physician prior
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Center for Emotional Wellness & Healing, LLC 100 Heritage Valley Rd, Ste. 1, Sewell, NJ 08080
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Policies and information:
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PSYCHOLOGICAL SERVICES AGREEMENT Jane Allemang, PhD, Clinical Psychologist CLIENT INFORMATION: TODAY S DATE: Name: Date of birth: Age: Sex: Relationship status: (circle) SINGLE MARRIED COHABITING WIDOWED
Instructions: All sections must be completed. If not applicable, please indicate as N/A. PATIENT INFORMATION
817 283 5252, Fax: 817 283 5283 Instructions: All sections must be completed. If not applicable, please indicate as N/A. PATIENT INFORMATION Last Name: First Name: M.I.: MALE FEMALE Home Address: City:
PLEASE PRINT CLEARLY
PATIENT INFORMATION FORM Rev. 02/2018 PLEASE PRINT CLEARLY New Patient Name Change Address Change Insurance Policy/Holder Change PATIENT INFORMATION Last Name: _ First Name: Middle Initial: DOB: Sex: Male
If it is not, call your insurance company and have them change the Children s Medical Center to one of Children s Medical Center physicians.
**This form is for your personal use only and is a tool to help you understand your personal health benefits** Call your insurance company (phone number on the back of your insurance card) and ask them
Our portals are encrypted and password-protected, too, so health data remains secure.
Patient Portal Education Sheet We know you re busy. That s why Palmetto Health-USC Medical Group s physician practices are offering a way for you to manage your health care online. We offer convenient
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RD Physical Therapy & Wellness, LLC Tel: 443-253-4603 Fax: 410-720-2690 Clinic Location : 3450 Ellicott Center Dr., Suite 105 Ellicott City, MD 21043 Patient information: Registration Form Last name: First
Cardiology Consultants of Atlanta, P.C N. Decatur Rd. Suite 395, Decatur GA, (404) phone (678) fax
OFFICE POLICIES AND PROCEDURES Thank you for choosing Cardiology Consultants of Atlanta for your cardiovascular care. We realize that you have a choice in medical providers and are pleased that you have
Dear Patient, Now that you are 18 years old we need a signed copy from you on file. Attached is a copy of the HIPAA form.
Dear Patient, We have a signed consent form on file that one of your parents has signed giving us consent to treat you and, if covered, to bill the Insurance Company. Now that you are 18 years old we need
APM PATIENT INFORMATION. Date of Birth / / SS# - - Sex: q Male q Female. Address: City State Zip. Employer Phone # ( ) Occupation
APM PATIENT INFORMATION Date: / / Name: / / (Last) (First) (MI) Date of Birth / / SS# - - Sex: q Male q Female Address: City State Zip Home Phone # ( ) Work Phone # ( ) Circle preferred number for communication
DILIP TAPADIYA, M.D. INC. Demographic Form
Demographic Form 1. PATIENT Name Soc Sec No: City: State: Zip: Birthdate: Driver s License No: Sex: Home Phone: ( ) Cell Phone: ( ) Marital Status: Occupation: 2. RESPONSIBLE PARTY Name: Soc Sec No: City:
KORT New Patient Information
managed by: KORT New Patient Information Patient Address: City/State/Zip: E-Mail Address: Date of Birth: / / Age: Sex: Social Security Number: - - Marital Status: Home Phone: Cell phone: Employer/School:
MasterCare Physical Therapy, Inc.
Patient Financial Responsibility To all of our Patients: We will, as a courtesy, file your insurance claims for you. Please be advised that it is solely your responsibility to know and to understand your
IOANA A. BINA, M.D. Gastroenterology Tel: (707) Fax: (707)
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Today s Date: LLC REGISTRATION FORM (Please Print) PATIENT INFORMATION Patient s last name: First: Middle: Mr. Miss Marital status: Mrs. Ms. Single Mar Div Sep Wid Is this your legal name? If not, what