Patient Information. Current Complaints Mark your location of pain, discomfort, weakness, or issue with an "X".

Transcription

1 Patient Information Name (Last) (First) Gender Date of Birth Age M F Treating Physician Date of next MD appointment Hand Dominance Have you had medical testing? Date Left Right What brought you to physical therapy? X-Ray When did your symptoms start? MRI EMG CT Scan Did an accident or specific incident occur causing your symptoms? Other Have you had treatment for your symptoms? Date Have you previously experienced these symptoms? Physical Therapy Massage Chiropractic Did you have surgery for this issue? Yes No Injection If yes, what procedure did you have done? Medication Current Complaints Mark your location of pain, discomfort, weakness, or issue with an "X". If you have pain, what is your pain level? (0=no pain, 10=extreme pain) Other Please describe the type of pain you are experiencing (check all that apply) Sharp Burning Currently: Achy Shooting Dull Deep At best: Numb Superficial Tingling Other At worst: Is your pain more severe at a certain time of the day? If yes, when? How often do you experience your pain? Constantly (100%) Has your pain changed since the start of the Frequently (60%-90%) injury/episode? Improving Worsening Remains the same Occasionally (30%-60%) Does your pain cause difficulty sleeping? Intermittently (5%-30%) Yes No

2 Functional Abilities and Restrictions What activities were you able to perform prior to this injury/episode that you are currently unable to perform? Does any activity make your pain better? Does any activity make your pain worse? Work/Social History Occupation(s): Position/Job Duties: Past Medical History How would you classify your general Do you smoke cigarettes? Do you drink alcohol? health? Yes No Yes No Excellent Fair If yes, how many cigarettes/day? If yes, how many drinks and how often? Good Poor In terms of your general health, please check all that apply. Do you currently or have you ever had any of the following? Pacemaker Auto-immune Disorders Cancer/Chemo/Radiation Please list ALL surgical history and dates. Allergies Anemia Thyroid Trouble/Goiter Fatigue Metal Implants/Joint Replacements Shortness of Breath/Chest Pain Dizziness/Fainting Fibromyalgia Asthma, Bronchitis, or Emphysema Vision or Hearing Difficulties Weakness Night Pain High Blood Pressure Heart Attack and/or Cardiac Surgery Hernia Weight Loss/Gain Low Blood Pressure Diabetes (Type I or Type II) Bowel or Bladder Issues Epilepsy/Seizures Arthritis/Osteoarthritis/Rheumatoid Coronary Heart Disease Headaches Anxiety/Depression Osteoporosis Stroke/TIA Blood Clot/Emboli Current Pregnancy Medications Please list all current medications. Patient Therapy Goals What are your goals at the completion of Physical Therapy? Signatures To the best of my knowledge, I have fully informed my physical therapist as well as all necessary staff and personnel employed by Evolve Physical Therapy the history of my problem and current status. Patient name (printed) Patient signature Date Parent/Guardian Name (Printed) Parent/Guardian Signature Date

3 Patient Information Name (Last) (First) Address City, State Zip Date of Birth Emergency Contact Name (Last) Home Phone Work Phone Cell Phone (First) ( ) ( ) ( ) Home Phone Relation to Patient: Spouse Parent Other Condition Description of Problem: Cell Phone Work Phone ( ) ( ) ( ) Date of Onset: Referred by: Referral Information: Primary Insurance Carrier Name: ID Number: Group Number: Subscriber Name: Subscriber Date of Birth: Deductible: Max Visits: Coinsurance: Copay: Claim/Authorization Number: Subscriber Relation to Patient: Self Spouse Parent Other Employer Information Name of Employer Address City, State Zip

4 Secondary Insurance Carrier Name: ID Number: Group Number: Subscriber Name: Subscriber Date of Birth: Deductible: Max Visits: Coinsurance: Copay: Claim/Authorization Number: Subscriber Relation to Patient: Self Spouse Parent Other Have you ever been treated at Evolve Physical Therapy? Yes No Have you had any of the following treatments within the past year? (check all that apply) Physical Therapy Occupational Therapy Chiropractic Speech Therapy Other Have you previously had physical therapy for this condition? Yes No For Medicare Patients Only If yes, for how long? Are 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 play? Yes No If yes, what was the date of the injury? Was the athlete hurt at school or in a league? Was any accident report filed with the school or league? Yes No Name of school or league: Motor Vehicle Accident Injuries Only If you are receiving care for injuries from a motor vehicle accident, in what state did the accident occur? Claim Number: Patient or Guardian Agreements I acknowledge that Evolve Physical Therapy may disclose protected health information for the purpose of payment, treatment, and healthcare operations. Consent to Treatment: I consent to receive outpatient physical therapy services that are deemed medically necessary or appropriate by my physical therapist or physical therapist assistant. I am aware that the practice of rehabilitation therapy is not an exact science and I acknowledge that no guarantees have been made to me regarding treatment and the treatment results from the rehabilitation therapy. I understand that I have the right to ask questions at any time during my course of care. Consent to Treat a Minor: Patient Name: Patient DOB: / / The undersigned does hereby authorize Evolve Physical Therapy consent to evaluate and treat the above mentioned minor by employees of Evolve Physical Therapy without a Parent or Guardian present. I agree to pay Evolve Physical Therapy all amounts that are due and owing for services provided which are not otherwise paid for by Medicare, 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 attorney, the undersigned further agrees to pay all reasonable costs of collection including, but not limited to, reasonable attorney's fees. 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 Evolve Physical Therapy 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 Evolve Physical Therapy will not further use or disclose such film or images for any other purpose without my authorization or consent. Patient name (printed) Patient signature Date Parent/Guardian Name (Printed) Parent/Guardian Signature Date

5 Attendance Policy (Please read thoroughly) Evolve Physical Therapy strives to provide each patient with the highest quality of care while attempting to accommodate your schedule to the best of our ability. Therefore, we provide reserved time slots for each patient in order to ensure that the appropriate amount of time is dedicated to receive the necessary course of treatment. While we are sensitive to the fact that an emergency may occur in a rare instance, cancellations, especially last minute ones, along with patient no-shows, decrease our ability to accommodate the scheduling needs of the other patients. Additionally, no-shows display a complete lack of respect for your therapist and fellow patients. We must ask for your full cooperation with the following policy: If you are more than 15 minutes late for your appointment and fail to notify us, treatment may be cancelled and a $50.00 fee charged for missing the appointment. A scheduled appointment MUST BE CANCELLED AT LEAST 24 HOURS IN ADVANCE either through to info@evolveptnj.com or by phone at or a $50.00 fee will be charged for that appointment. Failure to show up for an appointment ( no-show ) without notifying us will result in a $50.00 fee being charged for that appointment. Furthermore, 2 consecutive, no-shows will result in the cancellation of all remaining scheduled appointments. All patients, regardless of insurance/third party payor, will be charged a $50.00 CANCELLATION FEE for each late, late-cancelled, or no-show appointment. THE PATIENT IS RESPONSIBLE FOR THE FEE, NOT THE INSURANCE/THIRD PARTY PAYOR. All cancellations and no-shows will be documented in your medical record and appropriately reported to your physician and insurance/third party payor. Repeated failure to comply with this Attendance Policy will result in your name being placed on a Schedule Based on Availability list. This will require you to call for an open appointment on each day you would like to receive therapy. We will do everything possible to accommodate you, as space on the schedule permits. We at Evolve Physical Therapy, believe that this policy is necessary for the benefit of all our patients, so that we may continue to provide high quality treatment and service to everyone. All of the staff at Evolve Physical Therapy appreciates your anticipated adherence and cooperation with this policy as we are here, as a team, to help you reach all of your goals. I, agree to provide an active credit card to Evolve Physical Therapy to maintain on file for cancellation fees that are accrued. Patient Acknowledgement/Signature Parent/Guardian Signature / / Date

6 The Health Insurance Portability and Accountability Act ('HIPAA") NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice of Privacy Practices (the "Notice") describes the privacy practices of Evolve Physical Therapy LLC: Evolve Physical Therapy LLC wants you to know that nothing is more central to our operations than maintaining the privacy of your personal health information ("PHI"). PHI is information about you that we obtain to provide our services to you and that can be used to identify you. It includes your name and other basic contact information as well as information about your health, medical conditions and related information. We take our responsibility to protect this information very seriously. Our Pledge Regarding Your Health Information We are required by law to protect the privacy of your health information and to provide you with this Notice explaining our legal duties and privacy practices regarding your health information. We are also required to notify you in the event there is a breach of your PHI. Our staff is required to protect the confidentiality of your PHI and will disclose your PHI to a person other than you or your personal representative only when permitted under federal or state law. This protection extends to any PHI that is oral, written, or electronic, such as information transmitted by facsimile, modem, or other electronic device. This Notice describes how we may use and disclose your PHI. In some circumstances, as described in this Notice, the law permits us to use and disclose your PHI without your express permission. In all other circumstances, we will obtain your written authorization before we use or disclose your PHI. This Notice also describes your rights and the obligations we have regarding the use and disclosure of your PHI. Under federal and applicable state law, we are required to follow the terms of the Notice currently in effect. We are required to follow state privacy laws when they are stricter (or more protective of your PHI) than the federal law. If applicable, please see state provisions at the end of this Notice. How We May Use and Disclose Your PHI Without Your Permission. Treatment, Payment or Health Care Operations Below are examples of how Federal law permits use or disclosure of your PHI for these purposes without your permission: Treatment: 1. PHI obtained by Evolve Physical Therapy LLC will be used to help formulate treatment regimens for you. We will document information related to the services provided in your records. We may also disclose your PHI to your physician to assist them in providing care to you. We may contact you to provide treatment-related services, treatment alternatives and other health-related benefits and services that may be of interest to you. 2. Payment: We may contact your insurer, payor, or other agent and share your PHI with that entity to determine whether it will pay for your treatment(s) and the payment amount. We may also contact you about a payment or balance due for services rendered to you at Evolve Physical Therapy LLC. 3. Health care operations: We may use and disclose your PHI to monitor the effectiveness and quality of our health care services, to provide customer services to you and to resolve complaints. We may also use your PHI to tell you about opportunities that may be of interest to you, such as benefits for preferred customers Business associates: We use contractors, known as business associates, to provide

7 certain services for us. These contractors are required by law and their agreements with us to protect your PHI in the same way we do. Other Limited Circumstances We may also use and disclose your PHI without your permission for the following limited purposes: Individuals involved in your care or payment for care: We may disclose your PHI to a friend, personal representative, or family member involved in your medical care. For example, if we can reasonably infer that you agree, we may provide treatment records and related information to your caregiver on your behalf. Disclosures to parents or legal guardians: If you are a minor, we may release your PHI to your parents or legal guardians when we are permitted or required under federal and applicable state law. Worker's compensation: We may disclose your PHI to the extent authorized and necessary to comply with laws relating to worker's compensation or similar programs established by law. Law enforcement: We may disclose your PHI in response to a court order, subpoena, warrant, summons, or similar process for law enforcement purposes; to identify or locate a suspect, fugitive, material witness, or missing person; as certain information about a death resulting from criminal conduct; about crimes on the premises or against a member of our workforce; and in emergency circumstances, to report a crime, the location, victims, or the identity, description, or location of the perpetrator of a crime. As required by law: We must disclose your PHI when required to do so by applicable federal or state law. Judicial and administrative proceedings: If you are involved in a lawsuit or a legal dispute, we may disclose your PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process. Public health: We may disclose your PHI to federal, state, or local authorities, or other entities charged with preventing or controlling disease, injury, or disability for public health activities. These activities may include the following: disclosures to report exposure to a disease, or risk for contracting or spreading a disease or condition. Health oversight activities: We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections, as necessary for our licensure and for government monitoring of the health care system, government programs, and compliance with federal and applicable state law. United States Department of Health and Human Services: Under federal law, we are required to disclose your PHI to the U.S. Department of Health and Human Services to determine if we are in compliance with federal laws and regulations regarding the privacy of health information.

8 Although we may not engage in the following activities, under federal or applicable state law, we are allowed to use or disclose your PHI without your permission for these purposes: Research: Under certain circumstances, we may use or disclose your PHI for research purposes. However, before disclosing your PHI, the research project must be approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to protect your PHI. Coroners, medical examiners, and funeral directors: We may disclose PHI to a coroner or medical examiner to assist in identifying a deceased person or to determine the cause of death, and to funeral directors to carry out their duties. Administrator or executor: Upon your death, we may disclose your PHI to an administrator, executor, or other individual so authorized under applicable state law. Organ or tissue procurement organizations: Consistent with applicable law, we may disclose your PHI to organizations engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant. Notification: We may use or disclose your PHI to assist in a disaster relief effort so that your family, personal representative, or friends may be notified about your condition, status, and location. Correctional institution: If you are or become an inmate of a correctional institution, we may disclose to the institution or its agents, PHI necessary for your health and the health and safety of others. To avert a serious threat to health or safety: We may use and disclose your PHI to appropriate authorities when necessary to prevent a serious threat to your health and safety or the health and safety of another person or the public. Military and veterans: If you are a member of the US armed forces or a foreign military, we may disclose your PHI as required by military command authorities if certain conditions are met. National security and intelligence activities: We may disclose your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. Protective services for the President and others: We may disclose your PHI to authorized federal officials so that they may provide protection to the President, other authorized persons, or foreign heads of state, or conduct special investigations. We May Use or Disclose Your PHI for other purposes only with you authorization. Your written authorization to use and disclose your PHI is required in order for us to: Use and disclose treatment notes containing your PHI (to the extent we hold any). Send marketing communications to you: If we will receive payment for making a marketing communication, we will state this in the authorization.

9 Receive payment in exchange for your PHI. In addition to the above situations, any other uses and disclosures of your PHI not described elsewhere in this Notice would be made only with your prior written authorization. You may revoke any such authorizations at any time by submitting a written notice to Evolve Physical Therapy LLC, Records & Disclosure at 516 Commerce Street, Franklin Lakes, NJ ; Fax to: (201) Your revocation will become effective upon our receipt of your written notice. Your rights with respect to your PHI You have the following rights with respect to your PHI: Obtain a paper copy of this Notice. You have the right to obtain a copy of this Notice at any time. You may do so by contacting Evolve Physical Therapy LLC, Attn: Records and Disclosure. The address, telephone and facsimile number are set forth in the box below. Inspect and obtain a copy of your PHI: You have the right to see and get a copy your PHI we maintain, which includes your prescription and billing records. You may request an electronic copy of your PHI records that we maintain electronically. To get a copy of your PHI, submit a written request to Evolve Physical Therapy LLC, Attn: Records and Disclosures (address provided below). You may also ask us to provide a copy of your PHI to son. In that case, your written request must be signed by you, must clearly identify the person to whom you want us to send the copy of your PHI, and must state where the copy is to be sent. We will respond to your request in writing within 30 days. A fee may be charged for the expense of fulfilling your request. Denial: We may deny your request to inspect and copy your record in certain limited circumstances. If we deny your request, we will notify you in writing and let you know if you may request a review of the denial. Evolve Physical Therapy LLC Records and Disclosures, 516 Commerce Street, Franklin Lakes, NJ Fax: (201) All requests must include patient's full name, date of birth, and address. Request an amendment. If you feel that your PHI we maintain is incomplete or incorrect, you may request that we amend it. To request an amendment, submit a written request to Evolve Physical Therapy LLC Attn: Records & Disclosure (address provided below). Requests must identify: (i) which information you seek to amend, (ii) what corrections you would like to make, and (iii) why the information needs to be amended. We will respond to your request in writing within 60 days (with a possible 30-day extension). In our response, we will either: (i) agree to make the amendment, or (ii) inform you of our denial, explain our reason, and outline appeal procedures. If denied, you have the right to file a statement of disagreement with the decision. We will provide a rebuttal to your statement and maintain appropriate records of your disagreement and our rebuttal. Receive an accounting of disclosures. You have the right to request an accounting of disclosures of your PHI for purposes other than treatment, payment, or health care operations. This accounting will also exclude disclosures: made directly to you, made with your authorization, made incidentally, made to caregivers, made for notification purposes, and certain other disclosures. To obtain an accounting, submit a written request to Evolve Physical Therapy LLC, Attn: Records & Disclosure (address provided below). Requests must specify the time period, not to exceed six years. We will respond in writing within 60 days of receipt of your request (with a possible 30-day extension). We will provide one accounting per 12-month period free of charge, but you may be charged for the cost of any subsequent accountings. We will notify you in advance of the cost involved, and you may choose to withdraw or modify your request at that time. Request communications of PHI by alternative means or at alternative locations.

10 You have the right to request that we communicate with you in a certain way or at a certain location. For example, you may request that we contact you only in writing at a specific address. To request confidential communication of your PHI, submit a written request to Evolve Physical Therapy LLC Attn: Records & Disclosure (address provided below). Your request must state how, where, or when you would like to be contacted. We will accommodate all reasonable requests. Request a general restriction. A general restriction is one that restricts or limits our use or disclosure of your PHI. To request a general restriction, you must identify in this request: (i) what particular information you would like to limit, (ii) Whether you want to limit use, disclosure, or both, and (iii) to whom you want the limits to apply. We will consider your request but are not required to agree. We have the right to terminate the restriction if: (i) you agree orally or in writing to terminate the restriction, or (ii) if we inform you of the termination, which becomes effective only for your PHI created or received after we inform you of the termination. To submit a general restriction, send a written request to Evolve Physical Therapy LLC, Records & Disclosure (address provided below). Request a plan restriction. A plan restriction is one that meets the following three condition (A) it is to restrict disclosure of your PHI to a health plan for purposes of payment or health care operations; (B) the PHI relates solely to a health care item or service for which you, or someone on your behalf, has paid us in full; and (C) the disclosure is not otherwise required by law. If you wish to request a plan restriction, you must do so separately for each prescription and subsequent refill event, and must make your request at the pharmacy before your medication is dispensed. Otherwise the pharmacy will automatically submit the claim to your health plan on record, if any, for payment. We will not agree to a plan restriction unless we have first received payment in full for the item or service. We will also not agree to a plan restriction if by law we are required to submit your PHI to the plan. If we do agree to a restriction, we will not apply the restriction in the event of an emergency. To submit a plan restriction, you must do so either in person at the pharmacy when you bring in your prescription or by telephoning the pharmacy before your prescription is sent to the pharmacy. Evolve Physical Therapy LLC, Records & Disclosure 516 Commerce Street, Franklin Lakes, NJ Fax: (201) All requests must include patient's full name, date of birth, and address. If you believe your privacy rights have been violated, you can file a complaint with Evolve Physical Therapy s Privacy Office at the address written below or the American Physical Therapy Association or with the Secretary of the United States Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized in any way for filing a complaint. Evolve Physical Therapy LLC s Privacy Office, Investigations & Incident Response 516 Commerce Street, Franklin Lakes, NJ Fax: (201) Changes to this Notice We reserve the right to change our privacy practices. We reserve the right to make the revised Notice effective for PHI we already have about you as well as any information we receive in the future, as of the effective date of the revised Notice. Upon request to the Privacy Office, Evolve Physical Therapy LLC, will provide a revised notice to you. Effective Date: This Notice is effective as of July 17 th, State Specific Provisions: NEW Jersey

11 HIV-related Information: We will not disclose HIV-related information except to you or your authorized representative, or as permitted by State law or required by federal law.

12 Acknowledgement of Receipt of Evolve Physical Therapy LLC s Notice of Privacy Practices I, (printed name) have received Evolve Physical Therapy LLC s Notice of Privacy Practices. Signature of Patient or Guardian: Date: / / Please detach and return this Acknowledgement to Evolve Physical Therapy LLC or to the address specified on the Notice.