Patient Information: In Case of Emergency: Physician: Insurance:

Similar documents
Marital Status Patient s Last Name First Initial Date of Birth S M D W. Home Phone Work Phone Mobile Phone . Address City State Zip

Registration Form. Gender: Male Last Name First Name Middle Initial Female. - - / / Social Security Number Date of Birth Age Occupation / Employer

First Name: M.I. Last Name: Date of Birth: Marital Status (circle one): Never Married Married Divorced Legally Separated. Widowed Partner Other

REASON FOR TODAYS VISIT Is this injury / condition related to your..

Worker s Compensation Intake Form

Personal Insurance Intake Form

Patient Registration & Health History

PATIENT INFORMATION Patient Demographics and Insurance

New Patient Referral and Insurance Verification Form

PATIENT INFORMATION. Last Name: First Name: Middle Initial: Sex: M F Preferred Name: Date of Birth (MM/DD/YYYY): Height: Weight: Mailing Address:

BenchMark Rehab Partners Welcome to

PATIENT REGISTRATION

Patient Demographic Sheet Please use Black ink only & print clearly Referred by:

Advanced Therapy Solutions

Patient/Guardian Signature: I hereby agree that the information above is true and accurate. Patient Medical History Form PATIENT MEDICAL HISTORY FORM

Medical Information Sheet

4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB): / /

PATIENT INFORMATION. Social Security Number: - - Home Phone: ( ) Work Phone: ( ) Cell: ( ) Nearest Relative: Phone: ( ) Employer Address:

EMERGENCY CONTACT INFORMATION PATIENT EMPLOYER INFORMATION GUARANTOR / POLICY HOLDER INFORMATION INSURANCE INFORMATION

Welcome to Southwest Diagnostic Center!

Patient Registration. D. INSURANCE (if applicable)

Current symptoms, conditions, and complaints:

uqua 6560 Greenback Lane, Citrus Heights, CA (916) Fax (916)

MasterCare Physical Therapy, Inc.

Informed Consent for Physical Therapy Services

MR #: Patient Name: Page: 1 of 4 MADISON SPINE & PHYSICAL THERAPY PATIENT DATA SHEET

KORT New Patient Information

MR #: Patient Name: Page: 1 of 4 ADVANCED PHYSICAL THERAPY PATIENT DATA SHEET. May we send you text messages relating to your care with us?

Best Time To Call. Referring Physician:

Patient Name (Last) (First) Date

4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB): / /

3 Emergency Contact. Eaton Chiropractic & Rehab Center. 1 Patient Information. 2 Insurance / Guarantor. 4 Accident Information. Emergency Contact:

MR #: Patient Name: Page: 1 of 4 HAMILTON PHYSICAL THERAPY SERVICES PATIENT DATA SHEET

Ravi Yalamanchili M.D, P.A. Patient Registration / Information Sheet Last Name: M.I. Sex: Female Male First Name: Marital Status:

City: State: Zip: Home Cell Work Alternate Phone: Address: Home Cell Work Sex: Male Female Marital Status: Single Married Other:

ACIC PHYSICAL THERAPY

Patient Registration. D. INSURANCE (if applicable)

One Stop Medical Center Tel:

KORT New Patient Information

Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL Phone: Fax:

Have you had Chiropractic Care Before? When? Where? What is your current complaint (be specific)?

Family History: Cancer Diabetes High Blood Pressure Heart Problems/Stroke Rheumatoid Arthritis

MR #: Patient Name: Page: 1 of 4 MAX MOTION PHYSICAL THERAPY PATIENT DATA SHEET. May we send you text messages relating to your care with us?

Please feel free to ask questions about this document. I have read the above guidelines and agree to the terms set forth by A Joint Effort PT.

Felix Linetsky, M.D. 611 Druid Road East, Suite 303 ~ Clearwater, Florida ~ (727) ~ Fax (727)

Palmer Center for Natural Healing 8600 E. Shea Blvd. #110, Scottsdale AZ

Physical Therapy Services of Ottawa County Patient Registration Form

Last Name First Name M.I. Street Address City State Zip. Home Phone ( ) Cell Phone ( ) Work Phone ( ) Emergency Contact: Name/Relation Phone Number(

Patient Information Page 1 of 2 *We cannot process your insurance claims without the required fields filled out.

Demographic Information

PATIENT INFORMATION. Last Name: First Name: Middle Initial: Address:

NEW PATIENT INFORMATION Salutation First Name MI Last Name Nickname

PRINT CLEARLY. Name: (first) (last) (m.i) Address: City: State: Zip:

Patient Information. Referred by: Primary Care Physician: Last Name: First Name: Mr. Mrs. Miss Other Middle Name: Preferred Name:

PHYSICAL THERAPY CENTRAL

Please Be Aware. Patient Signature: Date: (Signed by Parent or Guardian if under age 18 or dependent)

Do we have your permission to leave a message on your voic ? Referring Physician: PCP: Occupation: Employer: Primary Insurance: ID#: Group#

New Leaf Physical and Massage Therapy LLC 1 of 5 HEALTH INTAKE FORM. Name Date of Birth

New patient intake information

NEW PATIENT INFORMATION FORM

MR #: Patient Name: Page: 1 of 4 CAPE COD HAND & UPPER EXTREMITY THERAPY PATIENT DATA SHEET

ACKNOWLEDGMENT OF RECEIPT OF HIPAA PRIVACY NOTICE

Patient Registration Form

ONEACCORD PHYSICAL THERAPY CASA GRANDE, GILBERT & PHOENIX, AZ REGISTRATION FORM PATIENT INFORMATION. q Mr. q Mrs.

Acknowledgement of Receipt of Notice of Privacy Practices

PATIENT INFORMATION. Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex:

PRIME CARE PHYSICAL THERAPY, P.C. NEW PATIENT INFORMATION

Patient Information Form

Chief Complaint Form: Patient Name: Age: DOB: Occupation: Employer: Referring Physician: Town: Primary Care Physician: Town: Y N

PATIENT INFORMATION : Please present insurance cards to receptionist. INSURANCE: Please fill out only if you re NOT the subscriber

List any past surgeries that you have had throughout your lifetime (if none, circle NONE):

First Name: Last Name: Initial:

Corona-Temecula Orthopaedic Associates P H Y S I C A L T H E R A P Y A N D W E L L N E S S C E N T E R

Welcome to Precision Rehabilitation

920 NE 112 th Avenue, Suite 103, Vancouver, WA Phone: Fax:

PATIENT INFORMATION Patient First Name Middle Name Last Name Age Birth Date. Mailing Address City State Zip. Street Address City State Zip

PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING (INCLUDE PRESCRIPTIONS, OVER-THE-COUNTER MEDS AND HERBAL SUPPLEMENTS): NAME DOSE HOW OFTEN DO YOU

(Formerly AFCN Physical Medicine) A member of the Arkansas Family Care Network, P.A.

Integrated Spinal Solutions Patient Information

Advanced PT, LLC 200 W Douglas Ave, Ste 1040 Wichita, KS (866)

Date: First Name: MI: Date of Birth: / / Last Name: Social Security Number: / / Preferred Name: Sex: Gender: Marital Status: Single Married Other

Patient Information. Patient Name: Address . City State Zip. Birthdate Sex: Female Male Marital Status: Married Single Other

HEALTH QUESTIONNAIRE. Today s Date Date of Birth Age Referring Physician Occupation Tobacco/Nicotine Use: Yes No

APM PATIENT INFORMATION. Date of Birth / / SS# - - Sex: q Male q Female. Address: City State Zip. Employer Phone # ( ) Occupation

AVIDAPT avidapt.com

PATIENT INFORMATION EMERGENCY CONTACT

Before your first visit there are a few things we would like you to be aware of:

Professional Sports & Orthopaedic Rehabilitation Associates, LLC

Spinal & Sports Care Clinic, PS E Sprague Ave., Spokane Valley, WA 99216

WORKERS COMPENSATION - NO FAULT. Patient Name Patient Address. Patient's SS# Date of Birth Attorney Name _ Phone Number WORKERS COMPENSATION

Welcome! And thank you for choosing Advanced Physical Therapy, Inc.

Patient Registration Form

Aquatic Care Programs, Inc. Patient Information Date:

FREDERICKSBURG ORTHOPAEDIC ASSOCIATES, P.C. PHYSICAL THERAPY INSTITUTE PATIENT INFORMATION SHEET

Multi-Specialty Musculoskeletal Pain Relief Center

Patient Express Registration

Chiropractic Case History / Patient Information

All Care Physical Therapy Center Directions: Please fill in all spaces, if not applicable, please put N/A.

Is a 3 rd party settlement anticipated (lawsuit, auto accident, etc)? Yes No

Christos Vasakiris, D.C.,D.A.C.A.N. 350 West Montauk Highway Lindenhurst, N.Y, 11757

Transcription:

For office use only: Start of Care: ICD-9 Codes: Patient Information: Name: Address: City: State: IL Zip: Patient of Birth:_ Policy Holders of Birth: of Injury or Onset of Symptoms: Home Phone: Work Phone: Cell Phone:_ Social Security No: Marital Status: Married/Single/Widowed/Divorced Email: In Case of Emergency: If married, please provide spouse s name: Nearest relative not living with you:_ Nearest friend not living with you: Work Phone: In an emergency, whom would you like us to contact: Landlord: Physician: Physician: Phone #: Fax #: Address: City: State: Zip: Insurance: Type of Insurance: Medicare Do you have any other insurance coverage: YES NO Who is responsible for this bill? Whom may we thank for referring you? I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance of my account for any professional services rendered. I have read all the information and have completed all the answers. I certify that this information is true and correct to the best of my knowledge. I will notify you of any changes in my status or in the above information. Should it become necessary for City Center Rehabilitation West, Inc to send a patients account to a collection agency, the patient will be responsible for any and all fees associated with the collection effort of the account to include reasonable attorney fees, court costs, collection charges and interest. Signature

PATIENT HISTORY 1. Please list any current medical problems or reason for therapy: 2. Please list your current medications and dosages: 3. Please list any surgeries related to this problem: 4. Please list any tests related to current problem, i.e. xray, MRI, etc.: 5. Please list any treatments related to current problem, i.e. physical therapy, chiropractic, injections, etc.: 6. Please list any other surgeries you have had: 7. Please check any present or past medical problems: Heart Problems Cancer Hypertension Diabetes Seizures Fractures Arthritis Osteoporosis Circulatory Problems Respiratory Problems Allergies Vision Problems Hearing Problems Other: 8. Have you fallen 2 or more times in the last 12 months? Yes No 9. Are you here because you fell? Yes No 10. Do you have difficulty with walking or balance? Yes No Patient signature: :

ASSIGNMENT AND INSTRUCTION FOR DIRECT PAYMENT TO CITY CENTER REHABILITATION WEST, INC. Patient: Employer: Claim# or Group #:_ SSN# or ID #: I hereby instruct and direct that (name of insurance company) to pay by check made out and mailed to: City Center Rehabilitation West, Inc. 1627 4 th Street Peru, IL 61354 Or If my current policy prohibits direct payment to the therapist/clinic, then I hereby also instruct and direct you to make out the check to me and mail it as follows: Patient Name c/o City Center Rehabilitation West, Inc. at: 1627 4 th Street Peru, IL 61354 The professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment towards the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. A photocopy of this assignment shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case. d at: City Center Rehabilitation West, Inc this day of, 20. Signature of Policy Holder Witness Signature of Claimant if other than Policy Holder

INSTRUCTIONS: Rate your major area of pain on the 1-10 pain rating scale. Write down the number of your pain at the present time, your best time, and your worst time over the past 30 days. Remember the number refers to your pain. Not how strong or weak you feel. Number 1 is the low minimal pain and number 7 is low intense pain. 10 9 8 7 6 5 4 3 2 1 0 Unbearable High Intense Low High Moderate Low High Minimal Low No Intense Intense Moderate Moderate Minimal Minimal Pain YOUR PAIN RATING: Pain now: Best day: Worst day: I am getting better worse staying the same these last 2 months. Areas of discomfort: Location: Description: When does it occur: _ How often does it occur? What do you do to relieve your pain? XXX Pain OOO- Numbness I am % ready to return to work.

City Center Rehabilitation West, Inc ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I, have received a copy of City Center Rehabilitation West, Inc. Noticy of Privacy Practices. I have read and understand my rights re: the privacy of my medical records. Patient Signature _ Guardian Signature (if applicable) _ Witness-CCRW

2024 © financedocbox.com Privacy Policy | Terms of Service | Feedback