Welcome to Precision Rehabilitation

Transcription

1 Welcome to Precision Rehabilitation We are happy you have chosen Precision Rehabilitation for your therapy services. Customer Service is our utmost priority. In order to provide quality rehabilitation therapy to all of our patients we need your assistance in the following: We pride ourselves in being prompt, therefore, please arrive 15 minutes prior to your scheduled appointment so you can be prepared to work with your therapist when your appointment begins. Your therapist is only available for your scheduled time. Please be on time to your appointment as we may be unable to accommodate tardiness. If you arrive late to your scheduled appointment, your therapist will only be able to accommodate you for the remainder of your scheduled appointment time. Excessive tardiness to your scheduled appointment is grounds for discharge. All Deductibles, Copays, and Co-Insurance are to be paid on your date of service and prior to your scheduled appointment time. All cancellations must be made 24 hours prior to your scheduled appointment time. If you do not call prior to 24 hours, you will be charged a $35 cancellation fee. To cancel a Monday appointment, please call our office by Friday. To cancel your appointment, please call (562) If you do not reach the receptionist by Friday, you may leave a detailed message on our voic . We truly believe that the intensity of exercise helps maximize rehabilitation outcomes. While you are a current patient with us, you have access to our gym during business hours (Monday-Friday 8 a.m. - 5 p.m., with the exception of major holidays). Please note: The gym program is completely independent and the FES bicycle is not included in the gym program. Every effort will be made to accommodate your scheduling preferences. To ensure your schedule preferences throughout your care please discuss with your therapist recommendations for your treatment frequencies (we recommend doing this around the 15 th of the month) and upon doing so, see Front Desk Administrators Sincerely, Precision Rehabilitation

2 Patient Registration Form Patient Information Patient Name: (First, Middle, Last) Address: State: Zip: _ Phone: DOB: City: Alternate Phone: Check this box if you prefer NOT to receive news about Precision Rehab. Emergency Contact Name: _ Relationship: Phone: Demographics Gender: Male Female Marital Status: Single Married Other Height: Weight: Social Security Number: Employment Status: Employed Unemployed Retired Disabled Student Other: Occupation: Employer: Incident Information How did you hear about us? Website Yelp Physician Friend: Other: Physician Information Primary Physician: Referring Physician: Phone number: Phone number: Primary Insurance Insurance Name:_ ID #:_ Relationship of insured: Self Spouse Guardian Other Name of primary insured (if other than self): DOB of Primary Insured: Secondary Insurance (if applicable) Insurance Name:_ ID #:_ Relationship of insured: Self Spouse Guardian Other Name of primary insured (if other than self): DOB of Primary Insured: Patient Signature Date

3 Medical & Surgical History Please check if you have ever had any of the following: Arthritis Broken Bones/Fractures Blood disorders Cancer High cholesterol Low cholesterol Circulation/Vascular problems Depression Developmental or growth problems Diabetes High blood sugar Low blood sugar Dizziness Heart problems Head injury High blood pressure Low blood pressure Infectious disease (eg., tuberculosis, hepatitis) Kidney problems Multiple Sclerosis Muscular Dystrophy Parkinson s Disease Seizures/ Epilepsy Stroke Spinal Cord Injury Thyroid problems Respiratory or Lung problems Repeated infections Ulcers/Stomach problems Skin diseases Skin breakdown Osteoporosis Smoking Alcohol Illicit Drug use Other: Past Surgeries? Date: Reason: Past Hospitalizations? Date: Reason: Within the past year, have you had any of the following symptoms? (Check all that apply) Bowel or bladder problems Chest pain Coordination Problems Cough Difficulty sleeping Difficulty walking Dizziness or blackouts Headaches Hearing problems Heart Palpitations Joint pain Loss of balance Loss of appetite Nausea/Vomiting Pain at night Ringing in the ear Shortness of breath Vision problems Weakness Weight gain Weight loss Swelling Current medications & dosage: (please list or attach) Any allergies? (Please list): Women: Are you or could you be pregnant? Yes No If yes, due date: Print Name Signature Date

4 Please take a moment to fill out our medical history form so that we may better serve you. Chief Concern/Reason for visit today: Are you having any pain? Please refer to the pain intensity scale below to answer the following: Your Pain Levels: At best At worst Average Currently Please indicate on the pictures below where your pain is located. Pain Intensity Scale 0 No Pain 1 Low: No pain medications. 2 Normal levels of activity, 3 except for heavy types. 4 Moderate: Regular use of pain 5 6 medications. Activity is very limited, but functional for family and social roles 7 High: Regular use of pain 8 medications. Activity limited to 9 necessary. Treatments previously received for this condition? Surgery Physical Therapy Occupational Therapy Speech Therapy Chiropractic Massage Have you had any of the following tests for this condition? X-ray MRI CT scan Ultrasound EMG Other: Print Name Signature Date

5 Notice of Privacy Practices Receipt Precision Rehabilitation reserves the right to modify the Privacy Practice Notice to reflect HIPAA Regulatory Changes. Signature of Provider: Precision Rehabilitation_ I acknowledge that I was provided with the Notice of Privacy Practices of the Medical Practice named at the top of this page. Patient Name (Print): Patient Signature: Date: Signature of Patient Representative: (Required if patient is a minor or if adult patient is unable to sign for them self) Relationship to Patient: I hereby authorize one or all of the designated parties below to request and receive the release of any protected health information regarding my treatment, payment or administrative operations related to treatment and payment. I understand that the identity of designated parties must be verified before the release of any information occurs. Name: Name: Name: Relationship: Relationship: Relationship:

6 Financial and Practice Policies As you begin your course of treatment with Precision Rehab, we would like you to be acquainted with our policies and procedures. Eligibility and benefits will be determined at the time your claims are processed. SPEECH PATIENTS (SELF PAY): 1a. I understand I am financially responsible for the speech/language/cognitive/dysphagia therapy that I receive. Payment can be submitted via cash, check or credit card. I understand payment is expected at the time of service for treatment performed that day. SELF PAY & WELLNESS PATIENTS: 1b. I understand I am financially responsible for the therapy that I receive. I understand payment is expected at the time of service for treatment performed that day. For your convenience, we accept cash, check, or credit card. ***PLEASE INITIAL EACH ITEM BELOW*** 2. I understand that Precision Rehabilitation is not contracted and is an out of network provider with my health insurance, any treatment provided to me is payable at their cash rate. 3. I understand if I involve my health insurance at any time, I have been notified in advanced that I will be responsible to bill my own insurance. Precision Rehabilitation can only provide procedure codes and receipts as proof of payment for services received. 4. I understand that Precision Rehabilitation does not accept in network rates from non-contracted insurance plan as Precision Rehabilitation is not bound or obligated to such agreements and/or contracts. 5. Please note, you are personally responsible for payment for any supplies you receive such as: electrodes, theraband, gym balls, etc. Payment is due at the time of service. 6. I hereby acknowledge that I have received a copy of Precision Rehabilitation Health Information Privacy and Practices Act (HIPAA) forms. I further acknowledge that a copy of the current notice is readily available on the reception desk if I should need additional copies. 7. CANCELLATION POLICY: There will be a charge of $35.00 for no show appointments or cancellations with less than 24-hour notification. I will be personally responsible for any cancellation fees. Understand that if you no-show or cancel 3 times, you will be discharged from therapy services, unless unforeseen substantial circumstances caused the no-show or cancellation. Assignment of Benefits/ Release of Information/ Consent to Treatment I have read and I agree with the above policies. I hereby authorize/assign my therapy insurance benefits to be paid directly to Precision Rehabilitation. I also authorize Precision Rehabilitation to release any necessary information to process this claim. I authorize the release of any medical information necessary to process claims. By signing below, I confirm and authenticate the authorization for Assignment of Benefits and Consent to Treatment by Providers at Precision Rehabilitation. Print Name Relationship to Patient (if other than self) Signature Date

7 HEALTH CARE PROVIDER-PATIENT ARBITRATION AGREEMENT Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or services provided by the health care provider including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers or preceptorship interns who now or in the future treat the patient while employed by, working or associated with or serving as back-up for the health care provider, including those working at the health care provider s clinic or office or any other clinic or office, whether signatories to this form or not. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care provider s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the health care provider to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against the health care provider, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. Each party to the arbitration shall pay such party s pro rata share of the expenses and fees of the neutral arbitrator together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees or other expenses incurred by a party for such party s own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that the provisions of the California Medical Injury Compensation Reform Act shall apply to disputes within this Arbitration Agreement including, but not limited to, sections establishing the right to introduce evidence of any amount payable as a benefit to the patient as allowed by law (Civil Code ), the limitation on recovery for noneconomic losses (Civil Code ) and the right to have a judgement for future damages conformed to periodic payments (CCP 667.7). The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement. Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one processing. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and if not revoked will govern all professional services received by the patient. Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) patient should initial below. Effective as of the date of first professional services. Patient s Initials If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUEOF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. Precision Rehabilitation Health Care Provider s Signature (Date) Print Patient s Name By: Health Care Provider s Duly Authorized Representative (Date) Signature of Patient or Patient s Agent, Representative, or Parent (Date) As:_ Translated by (Date) Relationship to Patient