PATIENT INFORMATION. Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex:

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1 PATIENT INTAKE FORM (Please Print or Type. Once complete, either fax to , to or bring with you during your first session!) Today s date: PATIENT INFORMATION Patient s last name: First: Middle: address: q Mr. q Mrs. q Miss q Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex: q Yes q No / / q M q F Street address: Social Security no.: Cell phone no.: ( ) P.O. box: City: State: ZIP Code: Occupation: Employer: Employer phone no.: ( ) Chose clinic because/referred to clinic by (please check one box): q Dr. q Insurance Plan q Hospital q Family q Friend q Close to home/work q Yellow Pages q Other Other family members seen here: INSURANCE INFORMATION (Please give your insurance card to the receptionist.) Person responsible for bill: Birth date: Address (if different): Home phone no.: / / ( ) Is this person a patient here? q Yes q No Occupation: Employer: Employer address: Employer phone no.: ( ) Is this patient covered by insurance? q Yes q No Primary insurance name/plan q Subscriber s name: Subscriber s S.S. no.: Birth date: Group no.: Policy no.: Co-payment: / / $ Patient s relationship to subscriber: q Self q Spouse q Child q Other Name of secondary insurance (if applicable): Subscriber s name: Group no.: Policy no.: Patient s relationship to subscriber: q Self q Spouse q Child q Other IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.: ( ) ( ) The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize The Physio Fix or insurance company to release any information required to process my claims. Patient/Guardian signature Date

2 HEALTH HISTORY QUESTIONNAIRE PLEASE FILL OUT THIS FORM AS COMPLETE AS POSSIBLE. IT WILL ASSIST YOUR THERAPIST IN DEVELOPING A PLAN OF CARE FOR YOU. IF YOU HAVE ANY QUESTIONS, PLEASE FEEL FREE TO ASK FOR ASSISTANCE. THIS INFORMATION WILL REMAIN CONFIDENTIAL UNLESS AUTHORIZED FOR RELEASE BY THE PATIENT. NAME: DATE OF BIRTH: / / OCCUPATION : HOBBIES: DATE OF INJURY: / / GENDER: WAS INJURY SUDDEN ONSET or GRADUAL ONSET (PLEASE CIRCLE) HAS THIS INJURY PREVENTED YOU FROM WORKING? YES NO IF YES, HOW LONG HAVE YOU BEEN OFF WORK? WORK STATUS: AT THE PRESENT TIME I AM ABLE TO: Work without restrictions Work the same job with restrictions Work a different job with restrictions Unable to work due to dysfunction Don t normally work outside the home Homemaker Retired Other IS AN ATTORNEY INVOLVED WITH THE CASE? YES NO IF YES, ATTORNEY NAME: PHONE: HAVE YOU SOUGHT PREVIOUS TREATMENT FOR THIS CONDITION? No other treatment Physical/Occupational Therapy Chiropractor Massage Therapy Psychiatrist/Psychologist Other: LIST ALL PRESCRIPTION MEDICATION YOU ARE TAKING (Including injection and skin patches: LIST ALL OVER-THE-COUNTER MEDICATIONS YOU ARE TAKING (Including vitamins and supplements):

3 PLEASE LIST ANY SURGERIES OR OTHER CONDITIONS FOR WHICH YOU HAVE BEEN HOSPITALIZED: DATE SURGERY/HOSPITALIZATION REASON ARE YOU CURRENTLY HAVING OR HAVE EXPERIENCED ANY OF THESE SYMPTOMS IN THE PAST 3 MONTHS? Fever Pins/Needles Vision Problems Chills Numbness Hearing Loss Night Sweats Shortness of Breath Headaches Bowel/Bladder Problem Skin Rash PLEASE CHECK ALL THE FOLLOWING CONDITIONS THAT APPLY TO YOU EITHER PRESENTLY OR IN THE PAST High Blood Pressure Chest Pain/Heart Attack Stroke Heart Disease Cardiovascular Disease Allergies: Epilepsy/Seizures Kidney Disease Asthma Emphysema/Bronchitis Tuberculosis Varicose Veins Dizziness/Fainting Depression Lung Disease Gout Hepatitis Arthritis Hearing Loss Chemical Dependency (alcohol/drugs) Thyroid Problems Emotional/Psychological Problems Other: ARE YOU AWARE OF YOUR CURRENT DIAGNOSIS? YES NO DO YOU HAVE QUESTIONS REGARDING YOUR DIAGNOSIS OR PROGNOSIS? YES NO OTHER COMMENTS OR CONCERNS YOU MAY HAVE: PAIN LEVELS: (O = NO PAIN, 10= WORST PAIN YOU HAVE EVER EXPERIENCED) MY CURRENT PAIN LEVEL IS: /10 MY PAIN RANGES FROM /10_TO /10 THROUGHOUT THE DAY DESCRIBE THE LOCATION OF YOUR PAIN: I WOULD DESCRIBE MY PAIN AS: MY PAIN GETS BETTER WHEN I: MY PAIN GETS WORSE WHEN I:

4 Additional Questions: Have you ever been treated at The Physio Fix? Yes/No If yes, when was this? Patient's Name: Have you had P.T.,O.T. or Chiropractic treatment this year? Yes/No. If yes, please indicate the type of treatment and the duration of treatment? Have you previously had PT for this condition? Y/N. If yes, for how long? For Medicare Patients Only: Have you currently receiving home care services? Yes/No If yes, when will you be fully done with home care? Do you have a home care discharge letter? Yes/No For Student Athletes Only: What sport(s) does the student athlete play? Was the student athlete injured during the performance of the sport? If yes, what date was the student athlete hurt? Was the student athlete hurt at school or in a league? If yes, was any paperwork filed with the school or league? Yes/No Name of School or League: Newsletter: In an ongoing effort to provide our patients with great customer service and the latest information regarding all of our client services, you may periodically received s from our company and its affiliates. If you prefer NOT to get these s, please check the box below: oopt out of Newsletter Patient or Guardian Agreement: o I acknowledge that The Physio Fix may disclose protected health information for the purposes of payment, treatment and healthcare operations. o I understand that I am responsible for any balance due and owing The Physio Fix for services rendered. All Patients: o CONSENT TO TREATMENT: I consent to receive outpatient rehabilitation therapy services and any ancillary services that are deemed medically necessary or appropriate by my physical therapist and/or treating physician. However, I am aware that the practice of rehabilitation therapy is not an exact discipline and I acknowledge that no guarantees have been made to me regarding treatment and the treatment results from the rehabilitation therapy.

5 Signature of Patient or Guardian: Date / / In conjunction with my care, I consent to allow the use of filming devices, such as a camera or cell phone, for the purposes of enhancing my care. In addition, I consent to the transmittal of such filming device images or video to The Physio Fix and/or the treating physician through or text. I acknowledge that such film and related images will only be used or disclosed for treatment purposes, and that The Physio Fix will not further use or disclose such film or images for any other purpose without my authorization or consent o Yes o No Financial Responsibility: I agree to pay The Physio Fix all amounts that are due and owing for services provided which are not otherwise paid for by Medicare, a third party insurance plan, a third party payor, or other payor source on my behalf for services rendered. In the event that this account is referred to a collection agency or an attorney, the undersigned further agrees to pay all reasonable costs of collection including, but not limited to, reasonable attorney s fees. Signature of Patient or Guardian: Date / /

6 Date: / / Authorization and Consent to Treat a Minor Patient Name: Patient Birthdate: / / The undersigned does hereby authorize The Physio Fix consent to exam and treat the above mentioned minor by employees of The Physio Fix without a Parent or Guardian present. Father or Guardian (signature) Mother or Guardian (signature) Witness (signature) Important Medical Information (Allergies, Medications, etc.):

7 Name: Patient Notification Policy In compliance with the Health Insurance Portability and Accountability Act ( HIPAA ) Privacy Rule and our Notice of Privacy Practices, The Physio Fix will not disclose your protected health information ( PHI ) without your explicit authorization, except as permitted by law for the purposes of payment, treatment and health care operations. Furthermore, The Physio Fix will limit the use, disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. Therefore, The Physio Fix will only disclose your appointment information, such as reminders or cancellations, on an answering machine, voice mail, text message or , unless you inform us otherwise. This notice refers to The Physio Fix as us and our, and to the patient/guardian as I, my, you, your, and yourself. I, the undersigned, hereby authorize The Physio Fix to disclose my appointment information by the following methods of communication and I assume all responsibility for ensuring that the methods of communication that I indicated below are secure, with password protection used where applicable: Answering Machine ( ) Voice Mail ( ) Text Message ( ) Patient/Guardian Signature: Date: If you choose to have your PHI communicated to individuals other than yourself, please accurately complete the information below and sign the authorization. I further agree to be responsible for notifying The Physio Fix if any of the foregoing change. I, the undersigned, hereby authorize The Physio Fix to disclose my PHI to the person(s) named below. Name: Relationship: Phone: Name: Relationship: Phone: Name: Relationship: Phone: Patient/Guardian Signature: Date:

8 CANCELLATION/ NO SHOW POLICY This Policy Agreement MUST be signed at initial appointment. Thank you for choosing The Physio Fix. Please read the following policies, initial each one, and then sign your name at the bottom of the page to acknowledge you agree to the following terms. Cancellation Policy: If you need to cancel an appointment, please call us ASAP (24 hours notice) so we have the opportunity to offer your appointment to another patient. If less than 24 hours notice is given, you will be charged a $35 cancellation fee. No Show Policy: If you do not show up for a scheduled appointment, you will be charged a $50 noshow fee. Late Policy: Since all of our appointments are 1-on-1, if you are late for an appointment, you have the choice to use the remaining length of your appointment time or you can choose to reschedule for another day/time and you will be charged a $35 fee. I understand the terms of this form. I realize that I am financially responsible for charges incurred from cancellations or no shows. Patient s Signature: Date: Patient s Name: Parent s Signature (if patient is a minor):

9 FINANCIAL POLICY Please carefully review our Financial Policies. It is important for you to have a thorough understanding of your Physical therapy benefits and responsibilities. NO INSURANCE / CASH RATE: The Physio Fix offers self-pay cash rates and packages to those who do not have insurance coverage, or those paying out of pocket towards a deductible, or those who have maximized their benefits. We also are allowed to take cash payment if you do not wish to involve your insurance at any point in time. MEDICAL INSURANCE COVERAGE: The Physio Fix participates in many commercial health plans, but not all. Prior to your initial visit we will gather the necessary information needed to verify your current insurance coverage and benefits. If you have not provided us with your insurance information prior to your first appointment, we have no way of verifying your benefits and you will be asked to pay the self-pay cash initial evaluation rate at the time of service. Once your benefits have been verified, the money you paid for the initial visit will become a credit on your account that can then be applied to your co-pay or deductible. It is ultimately your responsibility to know your physical therapy benefits and all coverage is based on insurance coverage at the time of service. CO-PAYMENTS AND DEDUCTIBLES: As part of our contractual agreement with your insurance company we must collect these fees directly from you. Often your annual deductible must be met before insurance will pay for physical therapy benefits. Co-payments will be collected at each visit. Please present your copayment upon arrival.

10 UNPAID BALANCES: Account balances over 60 days without a payment or payment agreement will be subject to assignment to an out of office collection assistance agency. Should this be necessary a transfer of $25 will be added to your account. NOTE: Verification of PT benefits is NOT a guarantee of payment. I have read and agree to the financial policies of The Physio Fix. I realize I am financially responsible for payment of my account with The Physio Fix regardless of my insurance coverage. Patient s Signature: Date: Patient s Name: Parent s Signature (if patient is a minor):

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