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Jordan Bradley
5 years ago
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Patient Intake Form Date: Name:,, SS#: Last First Middle initial Address: City: State: Zip: DOB: Male Female Height: Weight: Please check preferred phone number for contact: Home Phone: Cell Phone:

1 Patient Intake Form Date: Name:,, SS#: Last First Middle initial Address: City: State: Zip: DOB: Male Female Height: Weight: Please check preferred phone number for contact: Home Phone: Cell Phone: Work Phone: Address: Referral Source: Date of Injury/onset of condition: Have you ever been treated by physical therapy before for this condition? Yes No Is your condition work related? Yes No Motor Vehicle related? Yes No Emergency contact: Name: Relationship: Phone Number: I authorize Leading Rehabilitation to disclose my health information that is directly related to my current treatment to the individual(s) listed below for purposes of their role in my treatment or payment for the health services that I have received. Name: Relationship: Name: Relationship: What are your therapy goals?

2 Patient Name: Insurance Information Primary Insurance Name: Group #: Policy #/HICN: Insured Party: Self Spouse Parent Other: Secondary Insurance Name: Group #: Policy #/HICN: Insured Party: Self Spouse Parent Other: Are you currently Receiving Home Health care from a Nurse, Aide, Therapist or anyone other than a family member in your home? Yes No *Receiving home services at the same time as outpatient services may affect your coverage and reimbursement* Medical Doctor: Address: Phone Number: Fax Number:

3 Patient Name: Patient s Explanation of Physical Therapy Benefits of Primary Insurance Leading Rehabilitation office staff is working as a courtesy to you to determine eligibility and coverage of your insurance (s) for therapy services. On your behalf, we have contacted your insurance company and we were provided with the following information: Date of Contact: Phone # Name of Contact *This coverage determination does NOT guarantee payment by your plan* According to you insurer: You are are not eligible for PT services at this time Authorization Required? Yes No Medicare Part B Cap used: Remaining: N/A Visits Allowed: per Visits used: Visit Reset Date: N/A Policy Dates: Your copay is: per visit. Your coinsurance is: per visit Estimated cost to be paid at time of service per evaluation:, follow up visit You have an annual deductible of: $. You have paid: $ toward your annual deductible. Deductible met After your deductible has been satisfied, your treatment is covered at % (not including applicable co-payments or co-insurances. I understand that Leading rehabilitation will contact my insurance company to verify benefits as a curtesy, but that it is my responsibility to understand what is covered and required under my policy. I have provided all personal and insurance information accurately and I am responsible to inform Leading Rehabilitation of any insurance changes prior to the next treatment or be personally responsible for any charges incurred as a result of lapse of coverage. I understand that I am responsible for paying my co-payments, co-insurance and deductibles at the time of service which I acknowledge may be an estimate at that time. I understand that federal laws, state laws and insurance contracts make it illegal for Leading Rehabilitation to write off or wave any co-payments, co-insurance and/or deductibles. I understand that I am responsible for any balance due after payment is made by my insurance company. If I do not pay for charges that are my responsibility, I agree to pay Leading Rehabilitation collections costs including attorney and court fees. I have read the above statement and understand my obligation as stated. per

4 Patient s Name: Personal Medical History Please check all that Apply AIDS/HIV Anemia Angina Arteriosclerosis Arthritis Asthma Blood Clots Cancer Chemical Dependency Circulation Problems Depression Diabetes Epilepsy Heart Problems Hemophilia High/Low BP Joint/Bone Infection Liver Disease Lung Disease Multiple Sclerosis Pneumonia Stroke Tuberculosis UTI Osteoporosis Renal Failure Hypertension Migraines Hernia Seizures Dizziness Nausea/Vomiting Metal Implants Neuropathy Wounds Other: Recent Fractures (If yes please explain ) Recent Hospitalization (If yes please explain ) Please circle your response: Do you have a pacemaker? Yes No Defibrillator? Yes No Are you on a Blood Thinner? Yes No Are you pregnant? Yes No Have you been diagnosed with cancer? Yes No If yes, what type? Are you in remission? Yes, No Past surgical history: Is there any other pertinent medical history your therapist should be aware of? Are you presently taking medications (over the counter or prescribed by your MD? Please list medications.

5 Patient Name: Patient Authorization Record Initial here Authorization for Treatment I hereby authorize Leading Rehabilitation through its appropriate personnel, to furnish medical care and treatment to the named patient, considered necessary and proper in diagnosing and treating the identified condition in compliance with the New Jersey Statutes for Physical Therapy Practice. Authorization for Release of Information I agree that Leading Rehabilitation may provide information from my medical record to persons involved in my medical care. I authorize the release of medical information necessary to obtain payment of any benefits available to me to Leading Rehabilitation for services rendered. I agree that Leading Rehabilitation may obtain information from others who have provided medical care to me and/or are responsible for the payment of all or part of my bills when this information is needed in order to treat, bill, and/or receive payment. I have read Notice of Privacy Practices mandated by HIPAA Authorization for Release of Payment I request that my insurance company make all payments directly to Leading Rehabilitation for all services rendered. If my insurance prohibits payment to be made directly to Leading Rehabilitation, I agree to immediately pay over these funds to Leading Rehabilitation. Medicare and Private Insurances I agree that the information given to Leading Rehabilitation in applying for benefits under Medicare or any other private insurances are complete and accurate. I agree that Leading Rehabilitation may give Social Security Administration or its fiscal intermediary s information necessary to process claims. Workers Compensation/Motor Vehicle I agree that the information given to Leading Rehabilitation in applying for benefits under Workers Compensation/Motor Vehicle is complete and accurate. I agree that Leading Rehabilitation may give intermediary s information necessary to process claims. Patient signature / Guardian signature Date Printed patient name Signature of Leading Rehabilitation Staff

PATIENT REGISTRATION

7521 Virginia Oaks Drive #240 Gainesville, VA 20155 Ph: 703-753-7600 PATIENT NAME (FIRST, MIDDLE, LAST) PATIENT REGISTRATION DATE: HOME PHONE HOME ADDRESS CELL PHONE CITY STATE ZIP CODE SOCIAL SECURITY