PARAGON Physical Therapy, PC

Transcription

1 WELCOME TO PARAGON Physical Therapy. Who can we thank for referring you? We appreciate you choosing PARAGON Physical Therapy, PC to be your provider of physical therapy services. If you would not mind, please indicate below how you found out about our clinic. Your cooperation with this survey assists PARAGON to better anticipate present and future patient care needs. Patient Name: Evaluation : I was referred to PARAGON Physical Therapy by (please mark an X next to the statement below that best describes you): I am a returning patient who was treated previously at PARAGON. My primary care provider referred me to PARAGON. Please print full name of PCP: I was referred by a specialist provider (e.g., orthopedic, neurological, sports medicine, no fault, workers compensation) Please print full name of specialist provider: I was referred by a family member or friend. Please print full name of family member or friend: And family relation if applicable: I found PARAGON on the Internet. Other: Please describe

2 DEMOGRAPHIC INFORMATION DATE / / ADDRESS PERSONAL Name of Birth Age Address City Zip Social Security # - - Home Ph# Cell Ph# Emergency Contact Home Ph# PROVIDER INFORMATION Primary Care Doctor Referring Doctor/Surgeon WORK INFORMATION Work Ph# Relationship Ph# Ph# Employer Ph# Ext Address Occupation Status: F/T P/T Retired Not Employed INSURANCE Primary Insurance Ph# Address City Zip Name of Insured Relationship: self spouse child of Birth Social Security # - - Ph# Secondary Insurance Ph# Address City Zip Name of Insured Relationship: self spouse child of Birth Social Security # - - Ph# WORKERS COMPENSATION/ NO-FAULT INFORMATION Insurance Carrier Auto W/C Address City State Zip Claim # of Accident / / Cause Adjustor Ph# Ext Fax Attorney s Name Ph# Ext Fax Address City State Zip

3 Patient Name: PAST MEDICAL HISTORY FORM BLOOD PRESSURE Yes No JOINT CONDITIONS Yes No Hypertension Upper Extremity Low Blood Pressure Lower Extremity Normal Blood Pressure HEART DISEASE Yes No OTHER CONDITIONS Yes No Heart Attack Muscular Dystrophy Atherosclerotic Disease Rheumatoid Arthritis Myocardial Infarction Multiple Sclerosis Rheumatic Heart Disease Epilepsy Heart Murmur Gout Do you have a pacemaker? Fibromyalgia Diabetes MUSCLE CONDITIONS Yes No Hearing Loss Carpal Tunnel R/L Poor Eyesight Tennis Elbow R/L Fainting/Syncope Back Pain Polio Neck Pain Lyme s Disease Limited Limb Movements Other: LUNGS Yes No Asthma Emphysema Shortness of Breath EXERCISE WORK ACTIVITY STRESS LEVEL HABITS None Sitting Low Smoking Packs a Day 1-2x/week Standing Medium Alcohol Drinks a Week 3-4x/week Light Labor High Caffeine Cups a Week 5+x/week Heavy Labor Are you taking any seizure medications? Yes No If yes please list Are you taking any medications that might affect your heart, lungs, consciousness or general well-being while participating in therapy? Yes No If yes please list List all surgeries (including dates) Are you pregnant? Yes No Current week: Have you ever had any injuries related to work? Yes No If yes please list body part and date of injury Have you had any Auto Accidents? Yes No If yes please list body part and date of injury Have you ever had Physical Therapy or Massage Therapy before? Yes No Where?

4 MEDICATION RECORD List prescriptions, over-the-counter drugs, vitamins and herbal medicines. Patient name: Pharmacy name: Primary doctor name: Phone: Phone: : Medication/Dose What is medication for? Frequency Taken Route of Administration Allergies Other Signature of Patient, Parent, Guardian, Personal Representative

5 PAIN & SYMPTOMS STATUS REPORT Patient Name: : Using the symbols below please draw on the body diagram to indicate the location and type of pain you are having. ACHY PAIN BURNING NUMBNESS M M M M X X X X O O O O RADIATING PAIN > > > > > PINS & NEEDLES # # # # # # SHARP PAIN STABBING PAIN / / / / / / / My primary complaint is: The symptoms associated with my primary complaint began on: My secondary complaint is: The symptoms associated with my secondary complaint began on: Please circle on the scale below to indicate your CURRENT level of pain: No Pain Pain as bad as it gets Please circle on the scale below to indicate your AVERGE level of pain: No Pain Pain as bad as it gets Please circle on the scale below to indicate your WORST level of pain: No Pain Pain as bad as it gets What are the goals you expect to achieve by the end of Physical Therapy?

6 FINANCIAL POLICY While you are here are PARAGON Physical Therapy, PC, a few rules of the road: Assignment of Benefits: PARAGON Physical Therapy, PC will process all claims for payment. Therefore, we require you to sign an ASSIGNMENT OF BENEFITS form, which we will keep on file. If you wish to handle the claims process personally, the treatment fee must be paid at the time of service. Referral and Precertification: Please be sure to know your insurance coverage and copayments before your treatment starts. If your insurance requires a referral or precertification by your primary care physician, be sure to bring it in with you. If subsequent referrals are required, you will be responsible to hand them in when they are due. If you missed authorized visits, you will not be able to make them up. Co-payments: Your co-payment is due at the beginning of each treatment. You may pay by cash or check. Co-payments cannot be reduced or waived. Your financial responsibility is any portion of your deductible that has not been satisfied, and any dates of treatment not covered by your insurance. If you have any questions regarding coverage we urge you to call your insurance carrier. Patient Signature & Acknowledgement

7 ASSIGNMENT OF BENEFITS Dear Patient: As a patient of PARAGON Physical Therapy, PC we are able to accept your insurance for services rendered. We will submit a claim for your therapy procedures to your insurance company. While we are happy to provide this billing service to our patients, we do need your cooperation. By signing the Assignment and Release section below you are authorizing your insurance company to send their payment directly to us instead of yourself. Should an insurance company send a reimbursement check directly to you for services rendered here, you agree to send that check as payment to us immediately after endorsing the back of the check as follows: ENDORSEMENT: Pay to the order of: PARAGON Physical Therapy MAIL CHECK TO: PARAGON Physical Therapy, PC 50 N Industry Ct Deer Park, NY ASSIGNMENT and RELEASE: I Hereby Assign and Authorize all rights, privileges and remedies to payment of medical benefits to Cheryl Christie MS, PT, AT,C and PARAGON Physical Therapy, PC for services rendered by a licensed physical therapist or physical therapist assistant employed by Cheryl Christie, MS PT AT,C. to which I am entitled under insurance law. I understand that I am financially responsible for any balance not covered by my insurance. Notwithstanding any prior written agreement to the contrary, this agreement may be revoked by Cheryl Christie MS, PT, AT,C when payments are not payable based on the assignor s (patient) lack of coverage and/or violation of a policy condition due to the actions or conduct of the assignor (patient). I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I request all authorized benefit payments be made on my behalf. I hereby acknowledge that Cheryl Christie MS PT AT,C. will add a three (3)% charge on all past due balances, as well as the cost of any collections. PLEASE NOTE: IF YOU DO NOT HAVE A PRESCRIPTION FROM YOUR PHYSICIAN, PODIATRIST, NURSE PRACTICIONER, OR DENTIST, OR IF YOU HAVE BEEN RECEIVING HOMECARE, YOUR PHYSICAL THERAPY VISITS MAY NOT BE COVERED BY INSURANCE. Patient Signature Parent/Guardian Signature

8 PAIN DISABLILTY INDEX The rating scales below are designed to measure the degree to which aspects of your life are disrupted by chronic pain. In other words, we would like to know how much your pain is preventing you from doing what you would normally do or from doing it as well as you normally would. Respond to each category by indicating the overall impact of pain in your life, not just when the pain is at its worst. For each of the 7 categories of life activity listed, please circle the number on the scale that describes the level of disability you typically experience. A score of 0 means no disability at all, and a score of 10 signifies that all of the activities in which you would normally be involved have been totally disrupted or prevented by your pain. Family/home responsibilities: This category refers to activities of the home or family. It includes chores or duties performed around the house (eg, yard work) and errands or favors for other family members (eg, driving the children to school). No disability Worst disability Recreation: This category includes hobbies, sports, and other similar leisure time activities. No disability Worst disability Social activity: This category refers to activities that involve participation with friends and acquaintances other than family members. It includes parties, theater, concerts, dining out, and other social functions. No disability Worst disability Self Care: This category includes activities, which involve personal maintenance and independent daily living (e.g. taking a shower, driving, getting dressed, etc.) No disability Worst disability Occupation: This category refers to activities that are a part of or directly related to one s job. This includes nonpaying jobs as well, such as that of a housewife or volunteer worker No disability Worst disability Sexual behavior: This category refers to the frequency and quality of one s sex life. No disability Worst disability Life-support activity: This category refers to basic life-supporting behaviors such as eating, sleeping, and breathing. No disability Worst disability

9 FALLS EFFICACY SCALE On a scale from 1 to 10, with 1 being very confident and 10 being not confident at all, how confident are you that you do the following activities without falling? Take a bath or shower Activity Score: 1 = very confident 10 = not confident at all Reach into cabinets or closets Walk around the house Prepare meals (not requiring carrying heavy or hot objects) Get in and out of bed Answer the door or telephone Get in and out of a chair Getting dressed and undressed Personal grooming (i.e. washing your face) Getting on and off the toilet TOTAL SCORE

10 HIPAA NOTICE I,, hereby authorize Cheryl Christie MS PT AT,C d/b/a/ PARAGON Physical Therapy, PC to use and/or disclose protected health information pursuant to the Notice of Privacy Practices that is posted in this office. I have also been given the opportunity to review and/or receive a copy of these privacy practices. This authorization shall be in force and effect until such time that I give notification requesting the termination of this authorization. I understand that I have the right to revoke this authorization in writing at any time by sending such written notification to the attention of Cheryl Christie at 50 N Industry Ct, Deer Park, NY I understand that a revocation is not effective to the extent that PARAGON Physical Therapy, PC has relied on the use of disclosure of the protected health information. I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to inspect or copy the protected health information to be used or disclosed as permitted under federal or state law to the extent the state law provides greater access rights, and/or refuse to sign this authorization. Signature of Patient or Personal Representative Name of Patient or Personal Representative Person(s) we can discuss your care with other than your referring physician: THIS AUTHORIZATION IS BEING REQUESTED BASED ON THE NEW FEDERAL REGULATIONS THAT BECAME EFFECTIVE OCTOBER 2003 FOR ALL HEALTH CARE PROVIDERS.

11 CONSENT TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION Your protected health information will be used by this practice, known as PARAGON Physical Therapy, PC or disclosed to others for the purpose of treatment, obtaining payment or supporting the day-to-day health care operations of the practice. We are providing you with a copy of our Notice of Privacy Practices. We request that you review the notice prior to signing this consent. You may request a restriction on the use or disclosure of your protected health information. If you wish to restrict your disclosure, you should make that request in writing. This practice, however, may or may not agree to restrict the disclosure of your protected health information. If we agree to your request, the restrictions will be binding. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of federal privacy standards. You may revoke the consent to the use and disclosure of your protected health information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date of your revocation of consent is received will not be affected. This practice reserves the right to modify the privacy practices outlined in the notice. SIGNATURE I have reviewed this consent form and have reviewed the Notice of Privacy Practices. I give my permission to this practice to use and disclose my health information in accordance with it. Name of Patient (Print Clearly) Signature of Patient Signature of Patient Representative Relationship of Patient Representative to Patient

12 COMMUNICATION WAIVER I, hereby authorize Cheryl Christie MS PT AT,C d/b/a PARAGON Physical Therapy, PC and its employees to communicate via text messaging and with me regarding my treatment. I hereby waive any of my rights under the Health Insurance Portability and Accounting Act of 1996, better known by its abbreviation, HIPAA in connection with any text messages and/or e- mails from PARAGON Physical Therapy, PC and its employees. This waiver is not intended as a waiver of any of my other HIPPA rights (unless so stated in another document). This waiver shall be in force and effect until such time that I give notification requesting the termination of this waiver. I understand that I have the right to revoke this waiver in writing at any time by sending such written notification to the attention of Cheryl Christie MS PT AT,C at 50 N Industry Ct, Deer Park, NY Signature of Patient or Personal Representative Printed Name of Patient or Personal Representative THIS AUTHORIZATION IS BEING REQUESTED BASED ON THE NEW FEDERAL REGULATIONS THAT BECAME EFFECTIVE OCTOBER 2003 FOR ALL HEALTH CARE PROVIDERS.