Patient Medical History

Transcription

1 Patient Medical History Name: Social Security Number - - Age: Height: ft. / in. Weight: lbs. Who referred you to physical therapy? MD office Self Other Next Dr s appt: / / Referring Physician: Doctor Diagnosis: Employment/Work (Job/School/Play) Full-time Part-time ( hrs. /wk.) What is/was your Occupation? Homemaker Athlete Student Retired Not working Other/Position/Sport Restrictions Expected return to full duty/activity Employer: Employer Phone Number: - - Employer Address: City State Zip Please check one: Is the injury Work Related Auto Related or Other Accident Date of Injury / / Describe the Problem(s) for which you seek Physical Therapy Is there an attorney involved? YES NO Are you currently having or have you had Home Health services this year? YES NO If so, what was the discharge date? / / Who is your Primary Care Physician: When did you last see him/her? / / Please check any of the following whose care you are under: Physical Therapist Chiropractor Psychiatrist/Psychologist Medical Doctor/Osteopath Other: Have you, for any reason had out patient physical therapy this calendar year? YES NO If Yes approx. # visits? Have you had any of the following tests for THIS condition? (If yes, list date): X-- rays, MRI, CAT scan Bone Scan, Nerve/Muscle test, Other Result of test: Please list any surgeries (in/out patient) and any conditions for which you have been hospitalized and the dates: During the past month have you been feeling down, depressed or felt hopeless? YES NO During the last month have you been bothered by having little interest or pleasure in doing things? YES NO Do you currently smoke tobacco products? YES NO If yes, how many packs per day? How many days/week do you drink alcohol? If one drink equals one glass, how much do you drink during a sitting? Do you exercise beyond normal daily activities and chores? YES NO General Health Status: Excellent Good Fair Poor Have you had a fall in the last year? YES NO If so, approx. how many falls have you had in the last year? If you had a fall in the last year, was an injury sustained? YES NO If yes, please describe: If you had a fall in the last year, do you currently take Vitamin D supplements? YES NO Which of the Over-- the-- Counter medicines have you taken in the last week? Please check those that apply. Aspirin Tylenol Advil/Motrin/Ibuprofen Antihistamines Antacid Vitamins/Mineral Supplements Laxatives Decongestants Herbals- - Please Specify Please list any PRESCRIPTION medications, dosages, and frequency you are taking (including pills, injections, and/or patches): If your list of medications has been provided to us, please check here: 1. mg /day 2. mg /day 3. mg /day 4. mg /day 5. mg /day 6. mg /day

2 Have you EVER been diagnosed as having any of the following conditions? Please circle those that apply. Seizures/Epilepsy Cancer Diabetes Vision/Hearing Problems Osteoporosis PT Comments: Stroke/TIAs High Blood Pressure Heart Problems Pacemaker Hepatitis Tuberculosis Alzheimer s Circulation Problems Sleeping Problems Depression Weight/Energy Loss Asthma Emphysema/Bronchitis Parkinson s Chemical Dependency Thyroid Problems Multiple Sclerosis Gout Dehydration Orthopedic Surgery HIV/Aids Endometriosis Pelvic Inflammatory Disease Osteoarthritis Anemia Reviewed with no concern Do you ever experience any urinary or fecal leakage/incontinence with coughing, sneezing, jumping, or with a strong urge? YES NO Are you currently pregnant or think you might be pregnant? YES NO How many pregnancies have you had? Do you experience pelvic pain with intercourse, feminine product use or with pelvic exams by your doctor? YES NO We have specialized PTs who can treat these conditions. Would you like to speak with a therapist about this condition? YES NO Have you recently noted? Weight loss/gain YES NO Weakness YES NO Nausea/Vomiting YES NO Fever/chills/sweats YES NO Dizziness/Lightheadedness YES NO Numbness or Tingling YES NO Fatigue YES NO Night Pain YES NO What are your expectations of physical therapy? Pain Scale Please rank your pain, for the past two weeks, on this 0 10 scale. Zero is no pain Current Worst Best What aggravates your pain? Sitting Rise from sit Standing Lying Down Overhead Activity Lifting Squatting Stress Bending Walking Running Stairs Dressing Sitting Cough/Sneeze Turning Head Driving Looking Up/Down Straining Bowel Movements Urination Intercourse Other What eases your pain? Rest Ice Heat Changing Positions Medications Sitting Standing Activity Stress reduction/relaxation Other Please draw in your complaint using the diagram and markings. Also draw other pain areas that you have at this time. Ache Burning Pins and Needles Throbbing Other/General Pain ^^^^^^^^ ======= ooooooooooo //////////////// XXXXXXX ^^^^^^^^ ======= ooooooooooo /////////////// XXXXXXX For Therapist Use Only Reviewed by Therapist: Date: I do hereby state that the above information is accurate to the best of my knowledge. Patient Signature: Date:

3 Estimated Payment for Services Rendered As a courtesy to our patients, we will perform the initial insurance verification, complete any necessary reports, and file them with your insurance company to help with the collection process. Because of the variability among insurance group policies, it is YOUR responsibility and not that of RESULTS PHYSIOTHERAPY to understand your Outpatient Physical Therapy benefit with your insurance plan. Below is the information we received from your insurance company concerning your benefits: Primary Insurance Deductible Deductible Balance Out of Pocket Out of Pocket Balance Co pay/co insurance Calendar Year Visits Allowed Calendar Year Visits Used Secondary Insurance Deductible Deductible Balance Out of Pocket Out of Pocket Balance Co pay/co insurance Calendar Year Visits Allowed Calendar Year Visits Used THIS IS NOT A GUARANTEE OF BENEFITS. Please understand that RESULTS PHYSIOTHERAPY will file your insurances as a courtesy but does not accept responsibility for any misinformation RESULTS PHYSIOTHERAPY received. As the patient you are responsible for negotiating the settlement of any disputed claims and for all charges, regardless of anticipated insurance coverage. Please know that your account is considered delinquent if over 90 days old and may be sent to an outside source for collection. I agree to pay collection costs and/or attorney fees associated with collecting my delinquent account. Auto Accident If your health problem is the result of an auto accident, you must provide us with your auto insurance information and major medical policy information. We will file with your auto carrier if you have opened a personal car insurance medical pay claim otherwise we file with your medical insurance. We do not file with third party payers. You have the option to self pay should you choose not to file with your personal car insurance medical pay or medical insurance.

4 Health Insurance Deductible The deductible is the amount of money you pay for eligible medical expenses in a calendar year. After your deductible is met, you pay nothing or you share the REMAINING costs with your company, up to an out-of-pocket maximum. Coinsurance Coinsurance is a health care cost sharing arrangement between you and your insurance company. The cost sharing split typically ranges from 80/20 to an even 50/50. For example, if your coinsurance is 80/20, that means your insurer covers 80% of annual medical expenses and you pay the remaining 20%. The cost sharing stops when medical expenses reach your out-of-pocket maximum, which is usually between $1,000 and $5,000. If your medical expenses in a calendar year exceed your out-of-pocket limit, then your insurer covers all the remaining costs. There are medical plans with 100% coinsurance, which indicates all the medical expenses are covered by your insurer after your deductible is paid. Coinsurance rates may also vary in and out of your health care provider s network. Usually it is higher when going out-of-network. Out-of-Pocket Limit Your Out-of-Pocket Limit (also known as Out-Of-Pocket Maximum) is the maximum amount of money you may pay for medical services in a calendar year. Your Out-of-pocket limit may or may not include a deductible, depending on your insurer s definition. The maximum amount of money you may spend for health care services also may vary based on receiving care in- or out-of-network. Copayment Your Co-Payment or Co-Pay is the fee you pay for a doctor's visit. Co-Pays may also vary depending on whether you seek medical care in- or out-of-network, and if the doctor is considered a specialist.

5 Privacy and Benefits Informed Consent I understand that as a patient of RESULTS PHYSIOTHERAPY: o I have the right to receive complete and current information concerning my diagnosis (to the degree known by RESULTS PHYSIOTHERAPY), treatment, and any known prognosis. This information will be communicated to me in terms I can understand by my therapist. o I have the right to accept medical care or to refuse treatment to the extent permitted by law and to be informed of the medical consequences if I refuse treatment. I understand that if I refuse recommended treatment, RESULTS PHYSIOTHERAPY has the right to terminate the relationship with me. o I will be informed if RESULTS PHYSIOTHERAPY wishes to participate in or perform any research or educational projects that would affect my care. I understand that I have the right to choose whether I participate. I will receive the most effective care the clinic provides. o Patient s Rights will be posted in a prominent location at all clinics for my review and I can discuss any questions I have with my therapist. Privacy Policy: I acknowledge that I have received a copy of RESULTS PHYSIOTHERAPY Privacy Practices. I understand there is a copy of RESULTS PHYSIOTHERAPY Privacy Practices posted and it is my right to request a copy of the RESULTS PHYSIOTHERAPY Privacy Policy at any time. I also understand that as part of this organization s treatment, payment, or health care operations, it may become necessary to disclose my health information to another entity (my doctor, insurance company, etc.) and I consent to such disclosure for these permitted uses, including via fax. Is there anyone (family, spouse, children, or friend) involved in your care or payment related to your care that we can share your health information? YES NO If yes, Contact Person Name: May we contact you by phone for appointment reminders? YES NO address: (Important Note: We never share/sell your address, and you can opt out at any time.) How did you hear about us? Please check one. Physician Friend or family member Insurance Company I am a past patient Co worker Other Advertising Work Related Injury Sports team, school, club Other Internet/Website/Search Engine Assignment of Benefits I hereby assign all benefits directly to RESULTS PHYSIOTHERAPY and also authorize release of any medical records necessary to process medical claims. I understand fully that in the event my insurance company or financially responsible party does not pay for the services, I will be financially responsible for payment. Any overpayment will be reimbursed after all claims have been processed and paid through insurances. I, acknowledge and agree that Results Physiotherapy and any affiliates or vendor thereof, including collection or billing companies, may contact me by telephone or text message to any phone number I have provided, and any other phone number associated with my account, including wireless/mobile phone numbers. I further agree that you may use any method of contact to these numbers, such as an Automated Telephone Dialing System (ATDS) or prerecorded message. I also agree that I will notify Results if I have given up ownership or control of any such phone number. Patient s Signature 8/2015 Date

6 RESULTS PHYSIOTHERAPY APPOINTMENT POLICY A therapist will evaluate you on your first visit to RESULTS PHYSIOTHERAPY. At the end of your evaluation, your therapist will explain the frequency and type of treatment that you will receive. For example, office treatment three (3) times a week for four (4) weeks. Physical therapy is an intense, but brief treatment program for maximum pain relief and the goal of returning to the highest level of function possible. Missing an appointment will decrease the likelihood of these goals being met. If you are unable to attend one of your appointments, please provide 24 hours notice. It is in your best interest for your health to make up that missed appointment on a different day that week or that same day to ensure your condition does not regress. If you do not call to cancel and fail to show, we will give you a call that same day to reschedule your appointment. Please return our call as soon as possible so we may reschedule your appointment. If you miss three (3) scheduled appointments, a notice will be sent to your referring physician informing him/her that the treatment plan has not been adhered to and it is at your therapist s discretion to continue treatment or discharge you. We understand there are many legitimate life events such as illness, hospitalization, family emergencies, and uncontrollable circumstances that occur and we will always take these into account. If you are going to be late for an appointment please notify us, if possible, so that we can adjust or schedule accordingly. Please understand we will try to administer your full treatment; however, time restraints may limit us from doing so. It is our intent to work with you and your physician to address your needs and goals in the most effective way possible. We greatly appreciate your cooperation and look forward to helping you achieve a better quality of life. If you have any questions, please ask any of the RESULTS PHYSIOTHERAPY staff. Thank You. Patient s Signature Date 8/2015

7 RESULTS PHYSIOTHERAPY NOTICE OF PRIVACY PRACTICES Effective Date: March 1, 2015 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY. This notice describes Results Physiotherapy privacy practices and how medical information about you may be used or disclosed and how you can obtain access to the information. All of our locations follow the terms of this notice. In addition, all of our locations may share health information with each other for treatment, payment, or health care operational purposes described in this notice. All other uses and disclosures not described in this Notice will be made only with authorization from you. OUR PLEDGE REGARDING HEALTH INFORMATION: We at Results Physiotherapy understand that health information about you and your health care is personal and we are committed to protecting your health information. We are required by federal and state laws to maintain the privacy of your Protected Health Information (PHI) and to give you this notice explaining our privacy practices with regard to that information. Results Physiotherapy creates a record of the care and services you receive from us. This information is recorded to provide you with quality care and to comply with certain legal requirements. This notice applies to all records of your care generated by this health care practice, whether made by your therapist or others working in this office. This notice will inform you of the manner in which we may use and disclose health information about you. This notice also outlines your rights to your health information, and describes certain obligations Results Physiotherapy has regarding the use and disclosure of your health information. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that we use and disclose health information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. For Treatment: We may use health information about you to provide you with health care treatment or services. We may disclose health information about you to doctors, nurses, technicians, health students, or other personnel who are involved in treatment of your health. This includes the coordination or management of your health care with a third party. For example, information obtained by a physical therapist or other health care practitioner will be recorded in your record and will be used to determine your plan of care. This information may be provided to your physician or other health care professionals to assist in treating you. For Payment: We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about your office visit so your health plan will pay us or reimburse you for the visit. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. For Health Care Operations: We may use health information about you for operations of our health care practice. These uses are necessary to run our practice and ensure that all of our patients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide what additional services we should offer, what services are not needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where we can make improvements. As Required By Law: We will disclose health information about you when required to do so by federal, state, or local law. Marketing and any purposes which require the sale of your information: These disclosures require your written authorization. To Avert a Serious Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person as mandated by local statute. Any disclosure, however, would only be to someone able to help prevent the threat. Military and Veterans: If you are a member of the armed forces or separated/discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans Affairs as may be applicable. We may also release health information about foreign military personnel to the appropriate foreign military authorities. Workers' Compensation: We may release health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness. Public Health Risks: We may disclose health information about you for public health activities as mandated by local statute. Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

8 Law Enforcement: We may release health information if asked to do so by a law enforcement official, as mandated by local statute. YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU: You have the following rights regarding health information we maintain about you: Right to Inspect and Copy: You have the right to inspect and copy your PHI that may be used to make decisions about your care. Usually, this includes health and billing records. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to the Medical Records Coordinator. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and services associated with your request. The Right to an Electronic Copy of Electronic Medical Records: You have the right to request a copy of your electronic medical records to be given to you and/or have transmitted to another individual or entity. We will make every effort to provide the electronic copy in the format you request however it is not readily available but us we will provide it in either our standard format or in hard copy form (fees may apply). Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the information. To request an amendment, your request must be made in writing and submitted to the Medical Records Coordinator. In addition, you must provide a reason that supports your request for an amendment. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: is not part of the health information kept by or for our practice; is not part of the information which you would be permitted to inspect and copy; or; is accurate and complete. Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified. Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we restrict a specified health care professional from use of your information, or that we not disclose information to your spouse about treatment you received. We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must make your request in writing to the HIPAA Privacy Officer. In your request, you must list the information you want to limit and to whom you want the limits to apply; for example, use of any information by a specified health care employee, or disclosure of specified treatment to your spouse. Right to Request Confidential Communications: You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail to a post office box. To request confidential communications, you must make your request in writing to the Medical Records Coordinator. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice at any time. You may obtain a copy at any Results Physiotherapy location. Breach Notification: You have the right to be notified in the event Results Physiotherapy determines that a breach of your unsecured personal health information has occurred. Fundraising: We generally do not participate in fundraising with our patient information. If Results were to participate in fundraising activity, you have the right to opt-out of any communications to you for fundraising purposes. Restrictions on Disclosures to Your Health Plan: You have the right to request a restriction on certain disclosures to your health plan if the disclosure is purely for carrying out payment or health care operations and the requested restriction is for services paid out-of-pocket. Revocation: You may revoke the authorization at any time by submitting a written revocation and we will no longer disclose your PHI. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. CHANGES TO THIS NOTICE: We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility. The notice will contain the effective date on the first page. COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services Office for Civil Rights. To file a complaint with us, contact the HIPAA Privacy Officer at (615) There will be no retaliation against you for filing a complaint. QUESTIONS: If you have any questions about this notice, please contact the HIPAA Privacy Officer at (615)