fhe SPORTS ~ REHABILITATION CENTERI The Sports Rehabilitation Center of Dunwoody SCHEDULING INFORMATION We encourage patients to schedule at least two weeks advance, in order that you may reserve the time, which is most convenient for you. CANCELLATION & NO SHOW POLICY A broken appointment hurts three people: you, another patient, and myself. Please remember to cancel your appointment at least 24 hours in advance to avoid a $40.00 charge. INSURANCE Due to the constant changes in the insurance industry, it is impossible to keep up with each patient's individual plan. Please note, you WILL be responsible for any charges your insurance does not cover. Sincerely, The Sports Rehabilitation Center of Dunwoody
~ -.. REHABILITATION CENTERI New Patient Information Sheet Personal Last Name: ---'First Name: :MI: _ Address: City: ST:_Zip:, _ Email Address: Home #: Cell#: ---------- Date of Birth: ---'Age:, Gender: SS#:, _ Physician: Married ( ) Single ( ) Unknown ( ) (check one) Employment Employer: Office #:, _ Job Title: Yrs ofemployment: _ Employer Address: City: ST: Zip:, _ Insurance Information Insurance Company Name:...;Phone #: _ Address: City:--,-,ST:_Zip: _ ID# Group# W/C Claim#: -:-:-- --- (if applicable) Primary Insured: ( ) Self ( ) Spouse ( ) Parent ( ) Other () Employer Name ofinsured:.insureddate ofbirth: _ Address: City: ST:_Zip _ (if different from above) Home#:, Work#:, SS# of Insured: _ Insured Employer Name: ~ Insured Job Title:. _ Employer Address: City: ST:_Zip, _ Authorization to Release Medical Information!Assignment of Benefits I hereby assign all medical benefits to which I am entitled to The Sports Rehabilitation Center of Dunwoody in the event that they file insurance on my behalf and Iauthorize said assigns to release all information necessary to secure the payment of said benefits. I am aware that I am financially responsible for all charges whether or not paid by said insurance. A copy of this assessment shall be considered as effective and valid as the original. Signature of Patient or Responsible Party Date Midtown 555 10 th Street Atlanta, GA 30318 404-477-8888 404-477-8889 Dunwoody 5342 Tilly Mill Rd Dunwoody, GA 30338 678-812-4031 770-393-4374 Brookhaven 2669 Osborne Rd Atlanta, GA 30319 404-477.7777 404-477-7000 Sandy Springs 5290 Roswell Ste. W Atlanta, GA 30342 404-477-5555 404-477-5556 09/22111 Approval per GW
REHABILITATION CENTER 'FINANCIALIINSURANCE INFORMATION We will file all claims with your primary insurance carrier. However, we will need your assistance in any problems that may arise, as you are ultimately.responsible for your bill. You will need to pay the full amount of your bill until your deductible has been met Then the percentage of charges not covered by your primary insurance carrier will be collected on a weekly basis. Any remaining balance after your primary insurance coverage has been paid is due from you upon receipt of our bill. When verifying your insurance coverage, your insurance company may tell us your percentage of covered physical therapy charges (example: 80%). However, this is often misleading. Each insurance company has their own "reasonable & customary" fee schedule that they consider being acceptable charges. Insurance companies also may have "per visif' limits or may "not cover" specific charges. When we verify insurance, we strive to obtain as much information as possible. However, insurance companies after will only disclose a certain amount of information to us "the providers." We encourage you to verify the specifies of your policy with your insurance company in order to clarify exactly what is covered, not covered, etc. Any overpayments will be refunded after all charges have been processed by your primary insurance. Please be aware that secondary insurance will be your responsibility to file and collect. Charges We are unable to predict exact charges, as it depends on the therapeutic care you received by your therapist. Your first office visit to THE SPORTS REHABILITATION CENTER AT DUNWOODY is payable by you at the time of your appointment. We will gladly provide an explanation of charges upon your request. Medical Records Your medical records are held in the strictest confidence. If you wish information about your condition to be provided to a third party, they should provide us with a written authorization signed by you. Thank you for allowing us the opportunity to service you. If you have any questions about the above information or any uncertainty regarding your insurance coverage, please ask f()r,:assistance. I have read, fully understand, and will abide by THE SPORTS REHABILITATION CENTER of DUNWOODY policies. Signature of Patient or Responsible Party Date
THE SPORTS REHABI-L[TATlON CENTERI CANCELLATION AND NO SHOW POLICY The Sports Rehabilitation Center is committed to offering you the best possible treatment administered by out highly skilled staff We go to great lengths to ensure that your treatment experience is successful in achieving a rapid recovery. We have attempted to be flexible with our hours of operation and try to accommodate our patients' schedules without making them wait to get in for an appointment. However, any no-shows or cancellation mad within 24 hours means that we have unusable time slot. Therefore, cancellations and no-shows not made within 24 hours will be charged $40.00 cancellation fee. We will continue to provide the same high standard of care and ask that you commit to your scheduled appointment. **Your insurance carrier will not cover this charge** By signing below, I acknowledge that I have read and agree to this policy. Signature Date
fhe SPORTS ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES ***You may refuse to sign this acknowledgement*** I, have received a copy of The Sports Rehabilitation Center Notice of Privacy Practices. Print Name Signature Date For Office Use Only Date: ------------- Intials: ---- We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: o Individual refused to sign o Communication barriers prohibited obtaining the acknowledgement o An emergency situation prevented us from obtaining acknowledge o Other _
NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOL CAN GET ACCESS TO THIS INF6RMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVCAY OF YOUR HEALTH INORMATION IS IMPORTANT TO US. OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to grve )O~ this notice about our privacy practices, our legal duties and your rights concerning your health information, We must follow the pnvac y practices that are described in the notice while it is in effect. This notice takes effect 04/14/2003 and will remain in effect until W~ replace it. We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are perrnirted b> applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all ne2i:i': information that we maintain, including health information we created or received before we made the changes. Before we make 3 significant change in our policy practices, we will change this notice and make the new notice available upon request. You may request a copy of our notice at any time. For more information about our privacy practices or for additional copies of th J S notice, please contact us using the information listed at the end of this notice. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment and healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you Payment: We may use and disclose your health information to obtain payment for services we provide you. Healthcare operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may :5 iw e s authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect Unless you give us a written authorization, we cannot disclose your health information for any reason except those descried In the nonce To your Family and Friends: We must disclose your health information to you, IlS described in the Patient Rights section of this notice We may disclose your health information to a family member, friend or other person to the extent necessary to help with your he althcare or with payment of your healthcare, but only if you agree that we may do so. Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health infonnation that is directly relevant to the person's involvement in your health care. We will also use your professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other SImilar fonns of health information. MIDTOWN 555 10THSTREET ATLANTA, GEORGIA 30318 PHONE 404.894.9738 fax 404.894.1525 DUNWOODY 5342 TILLY MILL ROAD DUNWOODY, GEORGIA 30338 PHONE 770.395.2643 fax 770.396.2474 BROOKHAVEN 2669 OSBORf'\;: "C.=-:': ATLANTA. GEOR':::,:, 3:."- PHONE 404.477 '7 ii ; fa.< 404477 7000
Marketing Health Related Services: We will not use your health information for marketing communications with ou! your 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 information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health' or safety or the health or safety of others. National Security: We may disclose to the military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorize federal officials health informationrequired for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards and letters). PATIENT RIGHTS Access: You have the right to look at or get copies of your health information with limited expectations. You have the right to look at or get copies of your health information with limited expectations. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information you may obtain a form to request access by using the contact information listed at the end of this notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this notice. If you request copies, we will charge you.$.50 for each page, $25.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this notice for a full explanation of our fee schedule.) Disclose Accounting: You have the right to receive a list of instance in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities for the last 6 years, but not before 04114/2003. If you request this accounting more than once in a 12 month period we may charge you a reasonable cost-based fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions ~n our use or disclosures of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement. (Except in an emergency) Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you requested. Amendment: You have the right that we amend your health information. (Your request must be in writing and it must explain why the information should be amended.) We may deny your request under certain circumstances. Electronic Notice: If you receive this notice on our web site or by electronic mail (email), you are entitled to receive this notice in written form. QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this notice. You also may submit a written complaint to the US Department of Health and Human Services. We will provide you with the address to file your complaint with the US Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the US Department of Health and Human Services. Contact Officer: Joe Donnelly, PT Telephone: 404-477-8888 Address: 555 io" Street, Atlanta, Georgia 30318 Fax: 404-477-8889
REHABILITATION CENTER Circle YES or NO. Have you or any immediate family member ever been told you have:.... Self Family Cancer? yes No Yes No Diabetes? yes..no Yes No High blood pressure? yes..no yes No Heart disease? Yes No Yes No Angina/chest pain? Yes No Yes No Stroke?... Yes No Yes No Osteoporosis? yes..no Yes No Osteoarthritis? Yes No yes No Rheumatoid arthritis? Yes No yes No In the past 3 months have you had or do you experience: A change in your health? Yes No Nausea/Vomiting? yes No Fever/chills/sweats? Yes No Unexplained weight change? Yes No Numbness or tingling? Yes No Changes in appetite? Yes No Difficulty swallowing? Yes No Changes in bowel or bladder function? Yes No Shortness of breath? Yes No Dizziness? yes No Upper respiratory infection? yes No Urinary tract infection? yes No Patient Information: Patient Name: -------------------- Date: _ Circle YES or NO. Do you have a history of: Allergies/Asthma? Yes No Headaches? Yes No Bronchitis? Yes No Kidney disease? Yes No Rheumatic fever? Yes No Ulcers? Yes No Sexually transmitted disease?. Yes No Seizures? Yes No Are you currently: Pregnant? Yes No Depressed? Yes No Under Stress? Yes No Are your symptoms: (check one) o Getting worse 0 The same 0 Improving How are you able to sleep at night? (check one) o Fine OModerate difficulty DOnly with medication Check all that apply... Do you have a problem with... (check all that apply) Hearing 0 Vision o Speech D Communication Do you or have you in the past smoked tobacco? YES NO If yes, ----~ Packs X -------- Years. Last tobacco use ------- Do you drink alcoholic beverages? YES NO If yes, how many drinks do you routinely have per week? /week. Date of last physical examination _ List medications currently using:
Patient Name: Date: --------------------- ---------------- Please use the diagram below to indicate where you feel symptoms right now. Use the following key to indicate the different types of symptoms. KEY: Pins & Needles 00000 Burning = XXXXX Stabbing = 11111 Deep Ache = ZZZZ2. (-, )~1 --...,.~ lfuili, ow' - I- I J - 4 *, ''WI * J_