Patient Release of Information and Assignment of Benefits

Similar documents
Welcome to a Brighter Morgantown!

Acknowledgement of Receipt of Notice of Privacy Practices

Need help with frequent crisis, housing, transportation?

PATIENT INFORMATION FORM

New Patient Information and Forms

Patient Intake Form. How did you hear about us? (Please check one) Internet Doctor Referral Health Insurance. Friend/Patient Referral Drive- By Other

Sinha Clinic Foxfield Road, Suite 240, St. Charles, IL Office: (630) Fax: (630)

Our philosophy of care governs everything we do for you. It consists of the following key elements:

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

Linda Smoling Moore, Ph.D. Licensed Psychologist

Center for Emotional Wellness & Healing, LLC 100 Heritage Valley Rd, Ste. 1, Sewell, NJ 08080

Patient Information. Patient Name: (Last, First, MI) DOB: / / Home address: Home Phone: ( ) - Cell Phone: ( ) - Work Phone: ( ) -

New patient intake information

Patient Registration & Health History

PSYCHOLOGICAL SERVICES AGREEMENT

AGREEMENT AND INFORMED CONSENT FOR TREATMENT

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

Catherine A. Casteel, DPM 7501 Lakeview Parkway, Ste. 135 Rowlett, TX Phone Fax

First Name: Last Name: Initial:

Personal and Family Health History

SMILE ANALYSIS. How s Your Smile? YES NO (Look in the mirror as you answer these questions)

FLORIDA MEDICAL CLINIC, P.A. Your Life, Our Specialty

Welcome Letter. We look forward to working with you and your physician on achieving your goals with physical therapy.

PATIENT INFORMATION. Name Soc. Sec. # - - Last Name First Name Initial Address. City State Zip code. E mail address Sex M F Age Birth date

NEW PATIENT INFORMATION FORM

Spouse/Parent s Name Date of Birth / / Age Sex Relation to client Social Security # Phone Employed by Phone

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

Leslie Ellen Ackerman, Psy.D., PC

M F Last Name First Name Middle Initial Gender. Home Phone: Work Phone: Cell Phone: Physical Address: Mailing Address (if different):

Perpetual Motion Physical Therapy, Inc. Patient Information

Please list all current medications and supplements that you are taking:

Patient: Date: Address: City ST Zipcode. HPhone: Cphone . Can we leave message? Married Single Employed Student Full/PartTime

PATIENT INFORMATION. Name: Date of Birth: Age: Last name First Middle I. Home Address: City: State/Zip: Home Phone: Cell Phone:

Address: City/State: Zip: Billing Address: City/State: Zip: Home Phone: Cell Phone: Appointment reminder: Voice Text - Which #:

Patient Information: Date: Name: Married Single Minor Male Female Last First Middle Preferred. Birth date: S.S.N.# ID/DL#: Month /Day /Year

PSYCHOTHERAPIST-CLIENT SERVICE AGREEMENT

PATIENT APPLICATION FORM

NOTICE OF PRIVACY PRACTICES

Patient Health Information Consent Form

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

Regulatory Compliance

Center of Excellence in Spinal Care. Patient Information. If Patient is a minor Guarantor Name: If Patient is a minor Guarantor Social Security #:

GETTING TO KNOW YOU. 1. How important is it for you to keep your teeth healthy for a lifetime?

4601 Spicewood Springs Rd., Office (512) Austin, Texas Fax (512) DOCTOR-CLIENT SERVICES AGREEMENT

HAROLD GOODMAN, D.O SECOND AVENUE SUITE 405B SILVER SPRING, MD Patient Information

Consent for Services and Financial Policy

PSYCHOLOGICAL HEALTH ASSOCIATES, PA PSYCHOLOGIST-PATIENT SERVICES.

ACIC PHYSICAL THERAPY

Mary Holcomb, Psy.D., Licensed Psychologist 125 West Pineview Street, Ste Altamonte Springs, FL (407)

Welcome to Pediatric Therapy Center, PC!

Patient Information. Welcome. Here s what you can expect on your first visit:

Notice of Privacy Practices

Appointment Policy. Insurance Policy

Morris Medical Center, P.A.

Lake County Neuromonitoring, LLC Libertyville, Illinois Lake County Imaging, LLC P: Lakeshore Physical Therapy, LLC F:

Policies and information:

Name: Employer: Phone: Phone: Social Security: Occupation: Previous Therapy: Primary Doctor: Phone number: Fax Number: Referring Doctor:

PATIENT TREATMENT AGREEMENT

Who referred you to us? Who shall we contact in case of emergency? Phone:

Appointment Confirmation Policy

Last Name: First Name: Middle Name: Suffix: SSN: DOB: Gender: Height: Weight: Last Name: First Name: Relationship to patient:

GAHANNA COUNSELING, LLC

Welcome to MARTIN CHIROPRACTIC

OUTPATIENT SERVICES CONTRACT AND CLIENT INFORMATION

Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone

Allcare Rehabilitation

DIABETES & ENDOCRINE CENTER OF ORLANDO, P.A. WELCOME LETTER 3113 LAWTON ROAD, SUITE 100 ORLANDO, FL

Keri. Connections Family Therapy, LLC. Keri L Christensen LISW 1310 Tower Lane NE, Cedar Rapids, IA 52402

MasterCare Physical Therapy, Inc.

AUTHORIZATION FOR TREATMENT

Advantage Physical Therapy Patient Registration

Patient Information. Name Soc. Sec. # Last Name First Name Middle Initial. Address. City State Zip. Home Phone Cell Phone

South Lake Pain Institute

AUTO ACCIDENT INTAKE FORM

Patient Health Questionnaire

New Beginning Pediatric Rehab ~ Maryland s Trusted Rehabilitation Practice ~ (410) Office (877) Fax

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

Physical Therapy with care and knowledge

Family & Psychological Services Inc. Greentree Commons 951 Route 73 North, Suite B Marlton, NJ 08053

Myofascial Treatment Center of Modesto Patient Information Sheet

Referred By: Can we contact?

HARBORSIDE COUNSELING SERVICES CLIENT REGISTRATION

Informed Consent for Physical Therapy Services

TEXAS EAR, NOSE AND THROAT SPECIALISTS, L.L.P. NOTICE OF PRIVACY PRACTICES

Gastroenterology Specialists of Delaware, LLC

Welcome to our office!

WELCOME TO OUR OFFICE. Patient s Name: Today s Date: First Middle Last. Home Address: City: State: Zip: Telephone: Home ( ) Cellular: ( ) Work: ( )

Patient Health Summary

Name: Social Security: Address: City: State: Zip: Birthdate: Age: address: Cell Telephone: ( ) Fax: ( )

4. Who Is Accompanying the Child Today? 5. Responsible Party Information Name Name Relationship Birth Date Home Phone

Germantown Smiles,PC Germantown Road Suite 225 Germantown, Maryland

Thomas Yoon Dental Patient Information. Health Information

Suncoast Endoscopy of Sarasota

FOOTHILLS SPORTS MEDICINE AND REHABILITATION. PATIENT REGISTRATION FORM Please Print

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

PAMELA RAK, LCSW, P.C. INTAKE FORM (Please print clearly)

Patient Name: First Middle Last Address: Number Street (Apt#) City State Zip Address: Okay to Statement? Yes No

Olympus Family Medicine 4624 Holladay Blvd. Holladay, UT

Hello and Welcome to Soft Tissue Solutions

Kruse Park Chiropractic Clinic

Transcription:

Patient Release of Information and Assignment of Benefits Patient Name: Emergency Contact: Name Phone Number I agree to assign payment, be made directly to The Institute for Hand and Upper Extremity Rehabilitation, Inc., by my insurance carrier. I understand that the financial contract is between myself and the insurance company. Any payments made to me in behalf of The Institute for Hand and Upper Extremity Rehabilitation for services rendered will be turned over to The Institute for Hand and Upper Extremity Rehabilitation. I consent to treatment necessary for the care of the above named patient. I release authorization of records to my physician(s) and to the insurance carrier, if requested. I allow fax transmittal of my records. I acknowledge full financial responsibility for services rendered by The Institute for Hand and Upper Extremity Rehabilitation, Inc. I understand co-pay fees are due at the time of service, and that I will be billed for any patient responsibility after payment has been made by my insurance company if my plan indicates such a responsibility. I also understand that supplies, splints (either custom, fabricated, or other types of splints), or assistive devices are often not covered by insurance, and that I will be financially responsible for such costs incurred. Any legal fees and interest for non-payment of services after 4 months of billing will be my responsibility. Further collections will be instituted with a collection fee and interest charged at 1.5% per month. I will allow voice messages on my telephone by The Institute for Hand and Upper Extremity Rehabilitation Staff. I have read and fully understand the above consent for treatment, financial responsibility, release of information, and insurance authorization. Patient Signature or Responsible Party Date

Cancellation/No Show Policy Rehabilitation is a process which requires consistency in treatment. You will typically be scheduled for 2-3 visits per week. We understand that appointments must occasionally be cancelled. By reading and signing below, you agree to make every effort to telephone and inform us if you need to cancel an appointment and will adhere to the terms of this policy. You are expected to reschedule any missed appointments within the same week. It is appreciated if you call as soon as possible. If you do not show for an appointment, it is expected you reschedule that appointment. If you do not show for more than one appointment, you will be charged $35.00 each time that you do not call and do not show for an appointment. Any unpaid balance over 60 days will be forwarded for collection. I understand the above. Patient

Patient Policies Patient Responsibility If you need to cancel an appointment, you agree to call as soon as possible and reschedule the appointment within that week if at all possible. You agree to make a concerted effort to complete home exercises, including splint wear as instructed or shown to you by your therapist. The Use of Modalities Various forms of heat may be used to pre-condition tissue for exercise. They include hot packs, paraffin, fluidotherapy, and possibly whirlpool. It is important that you understand that these forms of heat are utilized according to standards set forth by professional therapy organizations. People, particularly following injury, may find their tolerance to temperature variable. Therefore, you may experience discomfort from heat used, particularly paraffin or hot packs. It is imperative that you inform the therapist if the heat you are experiencing is uncomfortable or feels like it is burning. Also, please inform the therapist if you have any sensory changes which may make you less able to perceive burning. Ultrasound is another form of heat utilized at times. You will typically feel no effect from the ultrasound, as it heats deeper tissue. Because of the nature of ultrasound, it may cause reaction to certain cellular growth and reproduction. Therefore, it is imperative that you inform your therapist if you are pregnant or have a history of cancer. Cold packs are occasionally used in therapy. These can occasionally cause burning as well. Please be sure to indicate to your therapist if you are experiencing any intense cold during cold pack application. Iontophoresis is sometimes used to treat inflammation due to tendinopathies. This utilizes an electrical charge to drive medication into tissue and may cause an electrical burn. If you feel a burning sensation during this treatment, again, inform your therapist of such. It is our goal to help and guide you through a positive therapy experience. We take a team approach to treating you and need your cooperation in this effort. Please sign below affirming your agreement to the above statements. Patient Date Therapist

HIPPA Compliance for Privacy Act It is our legal duty to maintain the privacy of your health information. We are required under federal law to provide you with this notice, and you may request a copy of this notice at any time. Disclosures of Health Information We use and disclose your health information, including medical reports, reports, and history, for the purpose of payment and healthcare operations. The following includes causes for this: Treatment: We may use or disclose your health care information to a physician or other healthcare professional providing treatment to you. Payment: Insurance companies, such as worker s compensation, auto, and some private companies, require information to obtain payment for services. You may give permission to disclose health care information to anyone for any purpose by notifying this office in writing. Without such written authorization, no information will be provided to any other group or individual, including family members unless the patient is a minor. We will not use your health care information for marketing without your specific written authorization. Required by law: We may use or disclose your health information when we are required to do so by law. Abuse or neglect: We may disclose your health care information if it is felt that you are a victim of abuse, neglect, domestic violence, or possibly a victim of other crimes. Appointment scheduling: A message may be left on a voicemail or answering machine regarding an appointment. This will be only a general message and not include any details regarding your care. Patient Rights: Access: You have the right to look at or get copies of your records and health information. Photocopies will be provided on request at a charge of $0.30 per page. The request can be made in person or by mail. You may request additional restrictions on your health care records, however, there is no guarantee of agreement to the restrictions set forth. If you feel that you require additional privacy with the treating therapist or other staff member to ensure your privacy, you are welcome to it. Your request can be made to any staff member regarding this request.

In order for the therapist to provide care to you, you must agree to allow medical reports to be sent as needed. Please initial next to each of the following acknowledging your consent to do so. Primary care physician Referring physician or physician assistant Insurance company Any other physician you request to be informed of your care Employer, if worker s compensation (optional) Lawyer (optional) Collection purposes Parent Signature of Client Date

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