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 NUMBER DATE OF BIRTH SEX AGE MARITAL STATUS EMAIL EMPLOYER OCCUPATION EMPLOYER S ADDRESS WORK PHONE REFERRING PHYSICIAN PHONE PRIMARY CARE PHYSICIAN (PCP) PHONE EMERGENCY CONTACT INFORMATION NAME PHONE RELATIONSHIP TO PATIENT INSURANCE COMPANY PRIMARY INSURANCE INFORMATION INSURANCE COMPANY PHONE NUMBER SUBSCRIBER S NAME SUBSCRIBER S DOB RELATIONSHIP TO PATIENT INSURANCE ID # INSURANCE GROUP NUMBER EFFECTIVE DATE OF POLICY SUBSCRIBER S EMPLOYER INSURANCE COMPANY SECONDARY INSURANCE INFORMATION INSURANCE COMPANY PHONE NUMBER SUBSCRIBER S NAME SUBSCRIBER S DOB RELATIONSHIP TO PATIENT INSURANCE ID # INSURANCE GROUP NUMBER EFFECTIVE DATE OF POLICY HOW DID YOU HEAR ABOUT OUR OFFICE PHYSICIAN REFERRAL PHONE BOOK ADVERTISEMENT WEBSITE FORMER PATIENT
MEDICAL HISTORY PATIENT NAME: DATE OF BIRTH: TODAY s DATE: Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia Yes No Muscular Disease Yes No Arthritis Yes No Fractures Yes No Osteoporosis Yes No Asthma Yes No Gallbladder Problems Yes No Parkinsons Yes No Autoimmune Disorde Yes No Headaches Yes No Rheumatoid Arthritis Yes No Cancer Yes No Hearing Impairment Yes No Seizures Yes No Cardiac Conditions Yes No Hepatitis Yes No Smoking Yes No Cardiac Pacemake Yes No High/Low blood pressure Yes No Speech Problems Yes No Chemical Dependency Yes No High Cholesterol Yes No Strokes Yes No Circulation Problem Yes No HIV/AIDS Yes No Thyroid Disease Yes No Currently Pregnan Yes No Incontinence Yes No Tuberculosis Yes No Depression Yes No Kidney Problems Yes No Vision Problems Yes No Diabete Yes No Metal Implants Yes No Describe any other conditions If "Yes" to Any of the above, please explain and give approximate dates/describe any other conditions Fall History Injury as a result of a fall in the past year? Two or more falls in the last year? Surgical History Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Current Medications -- Currently not taking any medications
Cancellation Policy Please notify us 24 hours in advance if you are unable to keep a scheduled appointment. The charge for the missed appointment or no-show will be $50.00. We have a recorder for your convenience, so you may leave a message for the next business day. A broken appointment affects three people 1. The patient who missed the valuable time 2. The patient who could have used the valuable time 3. The chiropractor who was fully staffed and prepared for the appointment Signature: Date: Print Patient s Name:
HEALTH INSURANCE AND WORKERS COMPENSATION INFORMATION & AUTHORIZATION PAYMENT POLICY: Our commitment is to provide you with the best possible care. In order to do this, we need your assistance and understanding of our payment policy so that billing and collection costs are minimized. HEALTH INSURANCE: If your health insurance is one that we participate with, you are responsible for a specified deductible and/or co-payment or co-insurance, as determined by your insurance company. Co-payments are due at time of treatment. Payment for several treatments may be made in advance if you so desire. Co-insurance will be billed to you after your insurance has made payment. If your insurance company denies payment, you will be held responsible for the entire amount of the bill. Deductible is collected at each visit until it is met. The patient will be notified once deductible is met. If the patient overpays the deductible amount, RESULTS PHYSICAL THERAPY Inc. will reimburse the patient. For patients without insurance, please see our full menu of services and prices at the front desk. These amounts are determined based on average reimbursement. WORKER S COMPENSATION: We will file a claim with your employer s workers compensation carrier upon your request and after you have initiated a claim for same. We must be provided with the necessary information. If your claim is denied, you will be held responsible for the entire amount of the bill. CANCELLATION POLICY: Please notify us 24 hours in advance if you are unable to keep a scheduled appointment, otherwise the charge for the missed appointment will be $50.00. You may call to leave a message at any time. With your signature, you agree to adhere to the above payment policy. Failure to adhere to payment policy does not in any way modify or waive the payment policy. In the event that RESULTS PHYSICAL THERAPY INC. or Lively Health, LLC. retains an attorney and/or collection agency to collect any unpaid balance of your bill, then by your signature to this document you agree to pay all costs of collection including collection fees, attorney fees in the amount of 1/3 of the principal balance in default, court costs, and other reasonable and related costs. By my signature below, I hereby authorize RESULTS PHYSICAL THERAPY INC. to apply for benefits to my insurance plan on my behalf for covered services rendered by same and request that payment be made directly to Results Physical Therapy Inc. I certify that the information I have reported with regard to insurance coverage is correct. I further authorize the release of any necessary information including medical information for this or any related claim. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by me in writing at any time. I HAVE READ AND UNDERSTAND THE FOREGOING STATEMENTS SIGNED DATE PRINT PATIENT s NAME:
Medical Information Release Form (HIPAA Release Form) Name: Date of Birth: Release of Information ( ) I authorize the release of all medical information rendered to me by Lively Health, LLC. This information may be released to: ( ) Spouse ( ) Child(ren) ( ) Other ( ) Information is not to be released to anyone. This Release of Information will remain in effect until terminated by me in writing. Messages Please call ( ) my home ( ) my work ( ) my cell number If unable to reach me: ( ) You may leave a detailed message. ( ) Please leave a message asking me to return your call. ( ) You may send a text message. The best time to reach me is (day) between (time) I authorize email communication to the following email address: Signed: Date:
Notice of Privacy Practices Receipt I acknowledge that the chiropractic practice named at the top of this page provided me with the Notice of Privacy Practices. Patient s Name: Patient s Date of Birth: Patient s Signature: Date: Patient s Acct #: If Signed by a Personal Representative Name of Representative: Signature of Personal Representative: Relationship to Patient: Signature of Results Physical Therapy Representative Date