VIRGINIA SPORTS MEDICINE INSTITUTE

Transcription

1 VIRGINIA SPORTS MEDICINE INSTITUTE PH FAX DATE NAME AGE OCCUPATION HEIGHT: WEIGHT: circle: MALE / FEMALE What area(s) of the body are you currently seeking treatment for? What area is most problematic at this time? Have you been treated for this same problem before? Have you ever had any cortisone, epidural, or other injections? When/Where? Do you exercise regularly or play sports? During the past year, have you been treated by any of the following? If so, please elaborate. Chiropractor Neurologist Psychiatrist Psychologist Osteopath Please list all relevant surgeries you have had in the past: Do you currently have/ever had a HISTORY of any of the following? (Please circle those that apply) Heart Disease Asthma High cholesterol Epilepsy/Seizures Stroke High blood pressure Congestive Heart Failure Depression Thyroid condition Osteoporosis Diabetes Type I or II Multiple Sclerosis Anemia Neurological condition Chronic infections Poor circulation Fibromyalgia Lupus Eating Disorder Blood clots Rheumatoid arthritis Migraines/headaches Hepatitis/Liver Vestibular disorder/fainting Alcohol use disease spells HIV/AIDS CANCER (list): Do you smoke/use tobacco? Do you have any heart problems? Describe: FOR WOMEN: Are you pregnant or planning to become pregnant? Do you have any implanted medical devices (e.g.- pacemaker, IUD, artificial joint)? Do you currently have OR are you experiencing any of the following? (Please circle those that apply) Pacemaker Fatigue Weakness Nausea/vomiting Internal Defibrillator Loss of bowel function Chest pain Dizziness Insulin Pump Loss of bladder function Numbness/tingling Fever/chills/sweats Do you have allergies? Please check all those that apply: o Adhesives o Latex o Shellfish o Iodine o Lidocaine Drugs (list): Other: Please list all medications you are taking, and the reason you take them OR indicate that you are providing a separate list. I CERTIFY TO THE BEST OF MY KNOWLEDGE THAT THE ABOVE INFORMATION IS COMPLETE AND TRUE. >>>SIGN HERE DATE: Signature of patient (parent or guardian if patient is under 18 years of age).

2 PLEASE READ THE FOLLOWING MESSAGE. Be advised: none of the pages or signatures in this packet are optional. There are no exceptions. It does not matter if you saw one of our doctors across the hall, if we have a copy of your insurance card or picture ID, or if you have been here before and nothing has changed since then. We appreciate your cooperation and we do apologize for any inconvenience this causes. Frequently asked questions: Q: Why do we need this information if you filled it out the last time you were here? A: The insurance companies require us to collect a new iteration of this information on you once per calendar year. We apologize for any inconvenience this may cause. Q: Why do I have to fill this out if you already have a copy of my insurance card? A: If you read the fine print at the bottom of the insurance information page, it states that by you filling out the information and signing below, that you authorize us to bill your insurance company. Simply giving us a copy of your card does not authorize us to bill. It is the completion of the form that legally authorizes us to bill your insurance company for services rendered. Q: Why do I have to fill this out if I have already seen one of your doctors across the hall? A: From a business perspective, the Virginia Sportsmedicine Institute is a division of the Nirschl Orthopaedic Center. However, from an insurance perspective, we are considered different practice types (physical therapy and orthopedic medicine, respectively). This is the reason that we each have our own separate versions of the paperwork, and we do appreciate your cooperation in filling out everything to completion so that we may properly bill your insurance company on your behalf.

3 VIRGINIA SPORTS MEDICINE INSTITUTE This page is not optional. Even if we have a copy of your insurance cards, we still ask that you complete this page in full. If any of these sections apply to you, they must be completed. Insurance companies require that we collect a copy of this information once per calendar year. Thank you. >PATIENT INFORMATION: Name: DOB: GENDER: MALE / FEMALE Home Address: City: State: Zip Code: Daytime Phone: Evening Phone: Guarantor s name and address if different from above: Guarantor s SSN: >INSURANCE INFORMATION PRIMARY INSURANCE: Insurance Company Name: Effective Date: Member ID: Group # (or Enrollment Code for Blue Fed): Subscriber s name if different from patient: Subscriber s DOB: Subscriber s SSN: >INSURANCE INFORMATION SECONDARY or SUPPLEMENTAL INSURANCE (Medicare Part G): Insurance Company Name: Effective Date: Member ID: Group # (or Enrollment code for Blue Fed) Subscriber s name if different from patient: Subscriber s DOB: Subscriber s SSN: >WORKERS COMPENSATION INFORMATION: Company handling your claim: Claim #: Adjuster s Name: Phone #: Fax #: Address for claim (City, State and Zip): Date of Injury: I,, hereby authorize the Nirschl Orthopaedic Center/Virginia Sports Medicine Institute to apply for benefits on my behalf for covered services rendered. I request payment from my insurance companies to be made directly to the Nirschl Orthopaedic Center. My signature certifies the information I have provided is correct and further authorizes the release of any necessary information, including medical information for this claim to be paid. This authorization is in effect for all future claims until I give written notice to revoke it. I permit a copy of this authorization to be used in place of the original assignment. I further acknowledge that I am financially responsible for any balances, deductibles and co-pays not covered by my insurance plan. Any accounts not paid in a timely fashion will be referred to an outside collection company. In the event that payment is not received and it becomes necessary, I understand I will be responsible to pay Collection Company and/or attorney fees in the amount of 33⅓% of the outstanding balance as well as any court costs associated with the collections process. >>>SIGN HERE DATE: Signature of subscriber or beneficiary (parent or guardian if patient is under 18 years of age).

4 What to Expect at Virginia Sportsmedicine Institute Physical Therapy Clinic Thank you for coming to Virginia Sportsmedicine Institute for your physical therapy treatment. We are glad you have chosen our facility for your care and know you will find our staff to be dedicated professionals who pride themselves on providing quality care to all clients. Our mission is to offer the highest quality of patient care. *On your first visit, please arrive at least 15 minutes prior to your appointment to fill out any necessary paperwork. Please note, at peak hours 10am-2pm the parking garage can get quite busy and it may take you longer to find a parking spot and get to our office. Please plan accordingly for this, as our office runs on time and we may not be able to see you if you are late* Please take time to familiarize yourself with the policies and procedures of this clinic. TREATMENT Services rendered must be covered by a current prescription. In order to bill your insurance company, we recommend that you have a prescription dated within the last 30 days of your appointment. WE WORK AS A TEAM. After your initial evaluation by a licensed therapist, your treatments may be scheduled with another licensed member of our rehabilitation team who will coordinate your care to help meet your rehabilitation goals. This helps you, the patient, have some flexibility in your appointment times and no gap in treatment if your therapist is sick, on vacation, or at a continuing education course. This team approach allows our therapists to pool together their collective knowledge based on their individual experiences, number of years in clinical practice and various backgrounds, creating diversity in treatment options to aid you in recovering more quickly. VSI is a sports medicine, exercise based, physical therapy clinic. To help in the delivery of exercises and post-operative protocols we utilize Certified Athletic Trainers, Physical Therapy students, and rehabilitation technicians. They will guide you through the exercises prescribed by your team. This team approach allows the patient more time to do their exercises here in the clinic to ensure they are completed correctly and answer any questions that might arise. If you are looking for a massage therapist, we are happy to give you a referral. In our 40+ years of doing business, we have found the team approach from our physicians, therapists, front desk staff, rehab techs, and you, the patient, allows for the most efficient quality and care. Your total treatment time will be approximately hours, consisting of 30 minutes of direct treatment with the Physical Therapist, and the remaining time with our rehab techs. This may vary slightly based on your needs. Remember, we work as a team; your therapists, rehab techs, and you, the patient. In order to allow timely communication with your referring physician, we ask that you notify us several days prior to your physician appointment so that we may forward a progress report to your physician s office, if appropriate.

5 ATTIRE FOR PHYSICAL THERAPY Please wear or bring comfortable, loose fitting clothing and appropriate footwear for your treatment. We encourage flat and/or athletic shoes. TARDINESS Please call if you are running late. Physical therapy treatments may be abbreviated for patients arriving minutes late. If you arrive more than 15 minutes late you may be asked to reschedule. We try to deliver the same respect for your time if we are running late, the session will be completed in its entirety. APPOINTMENT/CANCELLATION POLICY If you are unable to keep a physical therapy appointment, please notify us at least 24 hours in advance so that we may offer this time to other patients. If you must cancel and/or miss your previously scheduled appointment and do not provide the required notice, you will be charged a $25.00 fee. This fee is not covered by insurance. For Workers Compensation clients, we are obligated to inform your case manager or adjuster whenever a treatment session is missed. Finally, if you schedule an initial evaluation appointment and fail to keep the appointment, you will be charged a $ fee. I have read and understand the above guidelines. X Signature of Patient or Responsible Party Date

6 Nirschl Orthopaedic Center For Sports Medicine & Joint Reconstruction Virginia Sportsmedicine Institute Acknowledgement of Notice of Privacy Practices and Permission of Disclosure Release of Records Authorization I acknowledge that I was made aware of Nirschl Orthopaedic Center and Virginia Sportsmedicine Institute s Privacy Policy and a copy was available for my review (online and in the office). I authorize the following person(s) access to my protected health information (PHI) Name Relationship to patient This authorization remains effective unless revoked or terminated by the patient or the patient s personal representative. Right to terminate or Revoke Authorization You may revoke or terminate this authorization by submitting a written revocation to Nirschl Orthopaedic Sports Medicine Clinic. You should contact the Privacy Officer to terminate this authorization. Potential for Redisclosure Information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. It may not be possible to ensure your rightto the protection of the privacy of this information once Nirschl Orthopaedic Center and Virginia Sportsmedicine Institute discloses it to another party. X Signature of Patient or Responsible Party Date Notice of Disclosure of Ownership Interest Virginia Sportsmedicine Institute (VSI) is wholly owned by Nirschl Orthopaedic Center. The physician owners own the physical therapy clinic associated with Nirschl Orthopaedic Center. Because the physician s own the physical therapy center they are able to ensure the highest level of care is provided to you. A schedule of fees related to the services you might receive can be provided at your request. You have the right to request that service be provided at locations other than those described above. By my signature below, I am acknowledging this Notice of Disclosure of Ownership Interest on the date set forth below. X Signature of Patient or Responsible Party Date

7 FINANCIAL POLICY STATEMENT Nirschl Orthopaedic Center (NOC) & Virginia Sportsmedicine Institute (VSI) We are committed to providing you with the best possible care. In order to accomplish this, we need your assistance in reading and understanding the financial responsibility and our payment policy. RESPONSIBILITY FOR THE BILL It is the expectation that all patients/guarantors receiving services are financially responsible for the timely payment of the charges incurred. While the office will file verified insurance for payment of bills as a courtesy to the patient, the patient/guarantor is ultimately responsible for payment and agrees to pay the account(s) in accordance with the regular rates and terms of the clinic in effect at the present time. Not all services are covered by all insurance companies. It should be understood that by accepting the services, the patient is responsible for payment whether the insurance covered the service or not. The clinic cannot become involved with any third-party liability matters and must always look to the patient/guarantor for payment of the bill. POINT OF SERVICE COLLECTIONS Co-payments and deductibles must be paid upon the patient s arrival. We accept cash, checks, Visa, MasterCard, and American Express. We do not accept Discover. If you have an outstanding balance, we appreciate prompt payment in full. If you are unable to make payment in full, please inquire about arranging a payment plan with our bookkeeping department. Additionally, it is your responsibility to provide any necessary referral information to us that your insurance company requires prior to your visit. **It is extremely important that you notify us of any changes to your insurance information prior to each visit. Failure to do so can lead to unpaid/denied claims that the patient will be held responsible for** BAD DEBTS/LEGAL ACTION If multiple attempts to collect payment from you are unsuccessful, we reserve the right to turn the outstanding balance over to a collection agency. In addition to the principle balance, you will be responsible for the collections agency fee in the amount of 33⅓% plus any back interest due and/or any court cost that may be incurred. Any payment made to us in the form of a check that is returned for insufficient funds will incur a $25.00 fee per incident. CLAIMS HANDLING Our staff is trained to assist you with insurance questions. However, it is your responsibility as the patient to know and understand your physical therapy benefits. Coverage issues can only be addressed by your employer or health insurance plan. Although our assistance is available, we cannot act as a mediator on your behalf.

8 DURABLE MEDICAL EQUIPMENT There may be occasions when your course of treatment requires the use of an orthopaedic applicance or brace to facilitate your rehabilitation. Some insurance companies do not cover durable medical equipment. If you have any questions regarding this appliance or brace, do not leave the office with it in your possession. Due to health regulations braces, shoe inserts, gloves, putty, or any other such item cannot be returned. CONSENT The administrative staff and management welcome the opportunity to discuss any aspect of our financial policy. We appreciate your confidence and strive to provide quality healthcare. Your signature below indicates full understanding and consent to the above described policies. Additionally, I provide authorization to my insurance company to pay any applicable benefits directly to the Nirschl Orthopaedic Center and Virginia Sportsmedicine Institute. X Signature of Patient or Responsible Party Date