Patient Express Registration

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Patient Express Registration South Aiken Physical Therapy Todays Date: 1. Patient Info IMPORTANT: Please Fill-Out This Form Completely & Legibly (please do not leave any items blank) Your Full Name (check one Mr Mrs. Ms.) Date of Birth Gender: M F Email Address Home Address City State Zip Code Your Hm Phone ( ) Cellular ( ) Emergency Contact Person My condition is related to: Work Auto Accident (state ) Other: How did you hear about us? Why did you choose this clinic? Family MD If you were injured on the job, complete below; Social Security # Occupation Employer Name Adjuster Name Adjuster Phone 3. Important Info We are very committed to you and your goals. We will reserve appointment times for you that allow you the appropriate amount of therapist time for your needs. If you cannot keep your appointment, please call with 24 hours notice if possible so that someone else might benefit from that time. Failure to provide 24 hours notice will result in a fee to you. Nothing will be charged unless you cancel with less than a 24-hour advance notice ($10 fee) or fail to show ($25 fee). Phone 2. Payment Info (check only one box) I am not using health insurance. I am paying by CASH, CHECK, CREDIT and would like a... q 30% discount by paying at the time of service. q Payment plan. (Fees may apply). OR I have INSURANCE and would like to... q Have you deal directly with them. I will assign my benefits to you by completing the Assignment of Benefits Form. I understand that I am responsible for any deductible, copayment or co-insurance associated with my insurance plan. I also understand that my insurance plan may not cover all services received in Physical Therapy and that I am responsible for any non-covered expenses. My coinsurance/copay is $ My deductible is $ I was injured on the job and my employer will be paying for my Physical Therapy. (Please fully complete section 1.) 4. Appointment Reminders Would you like to receive appointment reminders for your future visits? Yes No If yes, choose ONE method to receive them? Text message Voice call (phone number) Email (please enter preferred email address)

Pre- Exam Questionnaire Patient Name: Date of Birth: Are you currently receiving any Home Health Agency Care? Yes No What is the main problem we are seeing you for today? Which side of your body is affected? Left Right Both Sides Not Applicable When did this problem start? Did you have surgery for this problem? No Yes When What procedure? BEFORE THE ONSET of this problem check any tasks you were unable to do, or had difficulty performing: Grooming Looking after your health Bathing Toileting Sleeping Driving Ability to Handle Phone Ability to Handle Finances Cooking Laundry Volunteer Caregiving Remaining Standing Squatting Kneeling Sitting Standing Move from bed to chair Turning in Bed Rising from a chair Need for Assistive Device Walking forward, back or sideways Walking around obstacles Climbing Running/Jogging/Skipping/Jumping Swimming Walk in home Stairs Walk in Community Walk in Large Building Walking on uneven terrain Pulling Objects Pushing Objects Reaching Turning or Twisting Hands or Arms Throwing Catching Picking up small items Gripping objects Manipulating small items Releasing small objects Kicking Pusing objects with your legs Work Wellness/Recreation 943 Pine Log Road, Aiken SC 29803 phone (803) 649 9797 fax (803) 642 2759 email: help@southaikenpt.com www.southaikenpt.com form rev 3/2016 Page1

Pre- Exam Questionnaire SINCE THE ONSET of this problem, check which tasks are difficult or are you unable to do? Grooming Looking after your health Bathing Toileting Sleeping Driving Ability to Handle Phone Ability to Handle Finances Cooking Laundry Volunteer Caregiving Remaining Standing Remaining Sitting Squatting Kneeling Standing Sitting Move from bed to chair Turning in Bed Rising from a chair Need for Assistive Device Walking forward, back or sideways Walking around obstacles Climbing Running/Jogging/Skipping/Jumping Swimming Walk in home Stairs Walk in Large Building Keeping balance if bumped in public Walking on uneven terrain Pulling Objects Pushing Objects Reaching Turning or Twisting Hands or Arms Throwing Catching Picking up small items Gripping objects Manipulating small items Releasing small objects Kicking Pushing objects with your legs Work Wellness/Recreation If we are seeing you for a pain problem today, please tell us more about it: Where is your pain? How would you rate your pain on a scale of 0-10 (0 is no pain, 5 is moderate pain, 10 is excruciating pain): At Worst, Currently, At Best Describe you pain further by checking all applicable descriptions: Burning Sharp Dull/Achy Throbbing Shooting Numb/Tingle Constant Intermittent Worse in AM Worse in PM Worse at Night Other: What makes your pain worse? What makes your pain better? 943 Pine Log Road, Aiken SC 29803 phone (803) 649 9797 fax (803) 642 2759 email: help@southaikenpt.com www.southaikenpt.com form rev 3/2016 Page2

Pre- Exam Questionnaire How would you describe your general health? Good Fair Poor Other: (For persons aged 65 or older only) How many falls have you had in the past 12 months (please circle): 0 1 2 or more Did any falls result in an injury (please circle): Yes No Please tell us more about your Medical History. Please check any that apply: I have no Known past medical history to affect treatment Alzheimer s Cardiovascular Disease Pacemaker Hypertension Stroke Diabetes Type 1 Diabetes Type 2 Fibromyalgia History of Cancer Immunosuppression Lupus Muscular Dystrophy Obesity Osteoarthritis Parkinson s Rheumatoid Arthritis Traumatic Brain Injury Other: If you have had any diagnostic tests for this problem please note here: (i.e. Xray, MRI, CT scans ) Do you have any unexplained weight loss? Yes No Medications: I am currently not taking any medications (proceed to next page) I have provided a separate medication list to scan into my medical record (proceed to the next question) Attention Medicare Beneficiaries: regulations require us to collect details about every medication you take: name, the dosage, the frequency and the route that the medication is taken (for example oral, injection, topical, sublingual). If you have not provided us with this list then please provide this information as detailed as you possibly can below: Prescription Dosage Route(oral/topical/sublingual/IV) Over The Counter Herbals Vitamin/Mineral/Supplements 943 Pine Log Road, Aiken SC 29803 phone (803) 649 9797 fax (803) 642 2759 email: help@southaikenpt.com www.southaikenpt.com form rev 3/2016 Page3

Pre- Exam Questionnaire List one or two things you are having difficulty doing now that you would like to be able to do better after Physical Therapy; i. ii. Signature (parent/guardian if under 18) Please Print Name Date OFFICE USE ONLY: Height (inches) Weight (pounds) Source: SAPT Outside medical record Blood Pressure Patient refuses height and weight measurement (N = Age 65 & older BMI 23 and < 30 kg/m2 ; Age 18 64 BMI 18.5 and < 25 kg/m2) 943 Pine Log Road, Aiken SC 29803 phone (803) 649 9797 fax (803) 642 2759 email: help@southaikenpt.com www.southaikenpt.com form rev 3/2016 Page4

Patient Name (please print) Date / / Consent to Treat The undersigned grants authority to South Aiken Physical Therapy, LLC (SAPT) and its staff to perform procedures and treatments deemed necessary for this patient and generally are used in the care of patients in this and similar Physical Therapy facilities. Additionally, the undersigned grants permission for the SAPT staff to provide emergency treatment if it is needed, or to transfer this patient to a local hospital for emergency treatment deemed necessary by the hospital medical staff. Signature of Patient/Parent/Guardian/Legal Representative Relationship to Patient (if applicable) Acknowledgement of Notice of Privacy Practices The undersigned acknowledges that he/she has been provided the option to receive a copy of the South Aiken Physical Therapy Notice of Privacy Practices. I understand that SAPT has the right to change it Notice of Privacy Practices and that I may contact SAPT at any time to obtain a current copy of the Notice of Privacy Practices Signature of Patient/Parent/Guardian/Legal Representative Relationship to Patient (if applicable) FRONT OFFICE USE ONLY PLEASE DO NOT WRITE BELOW THIS LINE I have attempted to obtain the patient s signature on this form, but was not able to for the following reason(s): Date: / / Initials:

Assignment of Benefits to South Aiken Physical Therapy, LLC Patient Name: Patient DOB: Policy Holder Name: Policy Holder DOB: I hereby instruct and direct by check made out and mailed to: insurance company to pay South Aiken Physical Therapy 943 Pine Log Road Aiken, SC 29803 803-649- 9797 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. (Check each box and sign below) q A photocopy of this Assignment shall be considered as effective and valid as the original. q I authorize the release of any medical or other information pertinent to my case to any insurance company, adjuster, or attorney involved in this case for the purpose of processing claims and securing payment of benefits. q I authorize the use of this signature on all insurance submissions. q I authorize South Aiken Physical Therapy, LLC to initiate a complaint to the Insurance Commissioner for any reason on my behalf. q I understand that I am financially responsible for all charges whether or not paid by insurance. Date / / Signature of Policyholder Signature of Claimant, if other than Policyholder If applicable, please read and sign below: I am 18 years old or younger and I hereby agree that South Aiken Physical Therapy may release any necessary payment information to my parent(s)/guardian(s). Signature of Patient Date / /

South Aiken Physical Therapy Patient Policies Creating the Best Rehabilitation Environment in Aiken: Our patients say that our care system is second-to-none. Here s what just a couple of patients have to say; I had almost immediate improvement and relief of symptoms. Book him! Alyssa D. I got better and the pain has not reoccurred. If you are considering this therapist you are making a good decision...i already have recommended him to family and friends Ron S. We attribute part of our success to the policies and beliefs we uphold; Important Patient Policies (Initial all boxes please) Do not be late. If you are more than 10 minutes late to your appointment you will be asked to reschedule. We avoid booking overlap as this compromises both yours and another patients care. Give 24-hr advance notice. A $10 fee* will be applied to your account for any reschedules or cancellations made with a less than 24 hour advance notice. Advance notice helps us schedule in place of you, other patients who need it. No-Shows are bad. We understand things happen. If you are unable to keep your appointment please call and let us know. Simply not showing up will result in a $25 fee* and the loss of all scheduled future appointments. New appointments will be allowed on a first-come, first-served basis. Payment is due at the time of service. How much you pay is a contract between you and the insurance company. We are not a party to that contract. We can deal directly with your insurance company for payment and to handle disputes if you sign the Assignment of Benefits form. You are responsible for payment of your account. Our fees are generally considered to fall within the range for this geographic area. Some insurance companies reimburse on an arbitrary schedule of fees and arbitrarily select which services to cover. Non-covered services are the responsibility of the patient. For insurance companies that we do not have a contract with, the patient is responsible for the difference between the amount billed and the amount paid by the insurance company. No unlawful waiver of patient responsibility payments. We are required to collect your portion of the invoice. No waiver, discounts, or special treatment can be awarded outside of documented financial hardship (federal guidelines used ask at the front desk for an application if you think you qualify). We accept cash, check, MasterCard and Visa. Accounts 30 days past due will be subject to 9.9% interest per month. Patient Responsibility Payment Extensions are available. If you are unable to pay your co-payment, co-insurance or deductible at the time of service you can make arrangements with the Receptionist to fill out a Request for an Extension Form. There is a $7.00 fee for this service to you. Individualized payment plans are available for a one-time $29 fee. A$25 charge applies for returned checks. I have carefully read and agree to all the above policies. In the event such policies are broken, I agree to the consequences set forth. Signed date / / * We take great pride in being a low patient volume practice and offering personalized service. These fees in no way cover our cost in keeping this spot for you. They are to encourage you to keep your appointments so that you may best achieve your goals or to call to allow us the time to offer your space to others who may need it. 943 Pine Log Road Aiken SC 29803 ph 803 649 9797 fax 803 642 2759 www.southaikenpt.com

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