MasterCare Physical Therapy, Inc.

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1 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 insurance coverage: deductibles, out-of-pocket expenses, co-pays, limits or caps, and whether we are a participating provider in your insurance network. If, for any reason, your insurance does not pay for any or all of your treatment here at MasterCare Physical Therapy you, as the patient or the legal guardian, are financially responsible for the outstanding balance. Medicare Patients: We have chosen to participate with Medicare. However, they cover only 80% of the allowed amount. Be advised that you or your supplemental insurance carrier will be billed the remaining 20%. HMO & PPO Patients: Associated co-pays are due at the time of service. I (patient s/guardian s name) accept responsibility for my bill. I authorize payment of all insurance benefits to MasterCare Physical Therapy, Inc. I agree to pay any charges that exceed or are not otherwise covered by my insurance. In the event that collection efforts are necessary, I agree to pay an additional 33.3% of the outstanding balance for the standard collection cost incurred. Patient s or Legal Guardian s Signature: Date:

2 Patient Information Sheet Patient s Full Name (Last) (First) (MI) Patient s Home Tel. No. Work Cell Address (Permanent) City State Zip Address (Seasonal) City State Zip Patient s Date of Birth / / Age Sex Marital Status Employer Name & Address Occupation Social Security Number Medical Diagnosis Referral Source Injury Date Are you currently receiving care from a Home Health Agency? Information for the person responsible for payment of the medical bills: Relationship to patient: Self Spouse Parent Other Name (Last) (First) (MI) Date of Birth / / Age Sex Social Security Number Nearest relative or friend NOT living with you that we may call in case of emergency: Name/Relationship Tel. No. Insurance: Medicare Medicare Supp. Private Workers Comp Auto Insurance Carrier Tel. No. Policy No. Group No. Claim No. I (Patient s name) hereby authorize MasterCare Physical Therapy, Inc. to render to the patient that which the patient s treating physician determines necessary or advisable. It is further understood that this clinic is authorized to carry out all instructions of the patient s physician and is relieved of all liability occurring from the performance of said instruction. I certify that information provided is true and accurate and I authorize MasterCare Physical Therapy, Inc. to disclose any information, including all or part of the patient s record, to any physician, government agency, insurance company, health care facility, workman s compensation carrier, or the patient s employer. The undersigned certifies that he/she has read the above agreement and as the patient or patient s agent, agrees to accept its terms. Patient s/legal Guardian s Signature: Date / /

3 Patient Medical History Sheet Patient Name Social Security Number Have you ever had any surgical procedures? Yes No If yes, please list: Please list all medications you are presently taking: Are you allergic to any food or medication? Yes No If yes, please list: Please check if you have ever had, or are presently being treated for: High Blood Pressure Heart Disease Diabetes Seizures Respiratory problems In case of an emergency, please list your hospital preference: _ Patient/Legal Guardian s Signature: Date:

4 PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION With my consent, MasterCare Physical Therapy, Inc. may use and disclose Protected Health Information (PHI) about me to implement Treatment, Payment and Healthcare Operations (TPO.) Please refer to MasterCare Physical Therapy, Inc. s Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. MasterCare Physical Therapy, Inc. reserves the right to revise its notice of privacy practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to MasterCare Physical Therapy, Inc. at 5560 Bee Ridge Road, Suite # D13, Sarasota, Florida With my consent, MasterCare Physical Therapy, Inc. may call my home or other designated location and leave a message on voice mail or to a person in reference to any items that assist the practice in carrying out TPO. This may include appointment reminders, insurance items, and calls in reference to clinical care or laboratory results. With my consent, MasterCare Physical Therapy, Inc. may mail to my home or other designated location any items that assist the practice in carrying out TPO. This may include appointment reminders or patient statements. I have the right to request that MasterCare Physical Therapy, Inc. restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to such requested restrictions, but if it does, it will be bound by such restrictions. By signing this form, I am consenting to MasterCare Physical Therapy, Inc. s use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures with my prior consent. If I do not sign this consent, MasterCare Physical Therapy, Inc. may decline to provide treatment to me. Signature of Patient or Legal Guardian Date Printed name of Patient or Legal Guardian

5 Patient Consent for Written and Telephone Communication Do we have permission to: Leave the following on your home answering machine or voice mail: Appointment Information Yes No Billing Information Yes No Medical Information Yes No Leave the following on your work answering machine or voice mail: Appointment Information Yes No Billing Information Yes No Medical Information Yes No I give permission to share appointment, billing and medical information with the following person(s:) Name(s:) Signature of Patient: Date:

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