Core Physical Therapy, PC & Integrated Center for Optimum Health, LLC

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Core Physical Therapy, PC & Integrated Center for Optimum Health, LLC New Patient Information (Please Print Clearly) Date: / / Patient Name: Sex: Male Female Last First M.I. Address: Street City State ZIP Parent or Guardian (If Patient is a minor): Is patient employed? Yes No Full-time student. Occupation: Employer or School: Marital Status: Married Single Other Home/Mobile Phone: Work Phone: Ext. E-mail: Date of Birth: / / Referring Dr.: Primary Care Physician: Phone: Phone: How did you hear about our office? EMERGENCY CONTACT: Name: Phone: Relationship: Primary Insurance Company: Secondary Insurance Company: Page 1 of 6

Health Information Date of onset: Surgeries Performed, including date: Height: Weight: Do you smoke: Yes No Any History of Falls: Yes No If Yes, when was your last fall: Medical History: No known medical history Diabetes Mellitus type 1 Previous therapy Arthritis Diabetes Mellitus type 2 Psycho-Social Cardiovascular disease Allergies Night pain Unexplained weight loss Surgical history Cancer Bowel/Bladder changes Osteoporosis Seizures Immune Deficiency disease Dizzy spells Other Did you require assistance/help with any of the following before the onset of your symptoms? Please mark all that apply. Activities of Daily Living/Daily Activities Care Giving Self care Mobility/Ambulation/Walking Work/Vocation Activities outside your Home/Travel Since the onset of your symptoms, do you have any pain or difficulties with the following? Sleep Sitting/Standing Self care Bending/Squatting Activities of Daily Living/Daily Activities Mobility/Ambulation/Walking Reaching/Pushing/Pulling Activities outside your Home/Travel Lifting/Carrying/Reaching Other: Which of the following make your pain worse? Sitting Standing Walking Stairs - up Stairs - down Lifting/Carrying/Reaching Sit to Stand Bending Laying Cough/Sneeze Pushing/Pulling Other: On the figure below: Mark the location of symptoms. Page 2 of 6

Primary concern/pain location: Pain scale 0 1 2 3 4 5 6 7 8 9 10 Mark the dots: No pain Moderate Severe At worst Current At best Since the onset of your symptoms are you getting: Better Worse No Change Pain description of primary concern: Burning Shooting Worse in AM Sharp Tingling/Numbness Worse in PM Dull/Ache Constant Other: Throbbing Intermittent ------------------------------------------------------------------------------------------------------------------------------------------ Secondary concern/pain location: Pain scale 0 1 2 3 4 5 6 7 8 9 10 Mark the dots: No pain Moderate Severe At worst Current At best Since the onset of your symptoms are you getting: Better Worse No Change Pain description of secondary concern: Burning Shooting Worse in AM Sharp Tingling/Numbness Worse in PM Dull/Ache Constant Other: Throbbing Intermittent ------------------------------------------------------------------------------------------------------------------------------------------ Diagnostic testing: X-ray PET Scan Angiogram CT Scan Ultrasound Cardiac Stress Test MRI Venous Duplex ECG EMG Holter Monitor Other: Specific findings/results: What makes your pain better: Current medications: What would you like to accomplish through therapy? i.e. Goals: Page 3 of 6

Core Physical Therapy, PC & Integrated Center for Optimum Health, LLC Financial Payment Policy Regarding Insurance: If we are a participating provider with your insurance company, then all co-payments will be collected at time of service. Deductibles, co-insurances, and account balances will be mailed out at the beginning of the following month from time of service. Financial Policy: As a courtesy, we will bill the insurance company for our patients, if we are provided the necessary information. This also includes Personal Injury Protection claims (PIP) and the state (L&I or private Worker s Compensation, Medicare and Medicaid). Your insurance is a contract between you, your employer (if applicable) and your insurance company. We are not a party to that contract. Therefore, it is the patient s responsibility to determine what their insurance company allows for therapy, obtain prior approval (if necessary) and follow up with their insurance company on all unpaid visits. Your insurance company determines the amount you are responsible to pay based on your plan policy with them. These amounts will be shown on the Explanation of Benefits which you will receive from your insurance company. It is your responsibility to know your co-payment amount, co-insurance amount, and whether a referral, a prescription, or pre-approval is needed for insurance coverage of your treatment. We do not bill third party. If you exhaust your PIP benefits, we will bill you or your primary insurance company. We do not wait for settlements. It is important to communicate any financial problems as soon as possible. Please contact the billing office directly at 206-447-5619 to discuss a mutually agreeable payment plan so you will not jeopardize your credit. Please advise the front desk of any changes that may affect your billing (i.e., employment, address, new injury, or insurance coverage). If your insurance company has not paid your account within 45 days, then the account automatically becomes your responsibility and will become due effective immediately. Please be aware that some 1 of 2

of the services provided may be non-covered services or not considered reasonable and necessary under your policy but deemed to be in your best interest by your provider. Should your insurance deny payment or coverage for any reason, you are responsible for any and all charges billed. A statement will be mailed to you after the denial has been received from your insurance company. This notice will hold for duration of your treatment for this injury. These denials may include, but are not limited to Medical Necessity Missing Required Documentation Investigational Coding Processing Dispute Exceeding Plan Limits Medical Supplies and Orthotics: Many insurance companies do not consider medical supplies a covered benefit. Therefore we ask for payment in full at the time of pick up if you are purchasing a non-covered item. Private (Cash-Rate): Private-pay patients are entitled to a discounted cash price when paid in full payment at the time of service. Interpreting your Explanation of Benefits (EOB): The following information may help you in understanding your statement. Total Charges: This is the total amount billed to insurance. This charge will be processed by the payer according to its contract with the facility provider. Allowed Amount: This is the total amount the facility expects to receive from insurance and/or patient combined. (It is also called the negotiated amount or expected amount.) Payable Amount: This is the amount that the primary insurance will pay. Patient Responsibility: This is the difference between the allowed amount and the payable amount. This represents any deductibles, co-insurances, and co-payments. If you have a secondary insurance, they may pay for all or part of the patient responsibility portion, depending on your contract. FULL PAYMENT IS DUE AT THE TIME OF SERVICE, UNLESS WE ARE BILLING YOUR INSURANCE FOR YOU. WE PREFER PAYMENT IN THE FORM OF AMERICAN EXPRESS, VISA, AND MASTERCARD. Seattle Tower Clinic 1218 3rd Ave, Suite 104 Seattle, WA 98101 (206) 447-2220 Phone (206) 447-2228 Fax info@seattlephysicaltherapy. com www.seattlephysicaltherapy. com Columbia Center Clinic 701 5 th Ave, Suite 213 Seattle, WA 98104 (206) 682-3122 Phone (206) 682-3126 Fax cc@seattlephysicaltherapy.c om Belltown Clinic 2505 2 nd Ave, Suite 100 Seattle, WA 98121 (206) 624-4020 Phone (206) 443-3999 Fax questions@belltownpt.com Edmonds/Shoreline Clinic 1227 N 205 th St Shoreline, WA 98133 (206) 546-2220 Phone (206) 546-2228 Fax questions@shorelinephysicalther apy.com Ballard/Crown Hill/Greenwood 8746 Mary Ave NW Seattle, WA 98117 (206) 784-2266 Phone (206) 784-2662 Fax info@physicaltherapygreenwood.com 2 of 2

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