PATIENT INFORMATION SHEET Chart #: Today s : FOA Initials: PATIENT INFORMATION Last Name, First Name, MI: Home Phone: Cell Phone: SSN: Birth (MM/DD/YYYY): Age: Sex: Marital Status: Single Separated Male Female Married Divorced Widowed Mailing Address: City State Zip Physical Address (911 Information): County / City: PATIENT S EMPLOYMENT INFORMATION Company: Occupation: Work Phone: Complete Address: INSURANCE INFORMATION Primary Insurance: Subscriber: of Birth: ID #: Group #: Is your Primary Insurance Medicare? Yes No Primary Care Physician (first & last name): Secondary Insurance: Subscriber: of Birth: ID #: Group #: Tertiary Insurance: Subscriber: of Birth: ID #: Group #: IF PATIENT IS UNDER 18 OR LIVING WITH PARENT(S) Father s Full Name: Father s SSN: Father s Address: Father s Phone: Father s Employer: Employer s Address: Work Phone: Mother s Full Name: Mother s SSN: Mother s Address: Mother s Phone: Mother s Employer: Employer s Address: Work Phone: SPOUSE S INFORMATION Spouse s Full Name: of Birth (MM/DD/YYYY): SSN: Employer: Employer s Address: Work Phone: PLEASE READ AND SIGN THE FOLLOWING: I have read and understand the information listed on this form. The information provided by me on this form is correct to the best of my knowledge. Patient / Guarantor (Page 1 of 5)
To All Patients: All professional services rendered are charged to the patient and are due at the time of service unless you have presented verification of insurance coverage for all diagnostic visits and procedures. If you are unable to pay for such services, please ask to speak to one of our collection specialists. Any collection fees charged by an outside collection agency for delinquent account balances will be charged directly to the patient. To Our Patients with Insurance Coverage: We will automatically file all charges with your insurance company once you have provided us your complete insurance information. We will ask to copy your insurance card for verification. Please remember your insurance coverage is a contract between you and your insurance. We will do everything possible to expedite your claim with proper filing and forms, however, YOU ARE responsible for all fees not paid by your insurance. To Our HMO Patients: It is your responsibility to obtain the proper referrals from your PCP. Our HMO contracts state that all patients must have a valid referral prior to their visit. Without this referral you will be asked to reschedule your appointment or to sign a waiver acknowledging no referral and your agreement to pay all charges in full. To Our Worker s Compensation Patients: If you were injured while in the course of your employment, we will file your compensation claim for you once we have verification from your employer that your claim is valid. We will still ask for your personal health insurance for future use if needed. You will be responsible for any charges not paid within (90) days by your Worker s Compensation Insurance Carrier. If at any time we can be of help with the expedition of your claim, please ask to speak to our Worker s Compensation Specialist. All Insurance / Worker s Compensation Patients: Please read and sign the following: I authorize the release of medical information to my insurance carrier(s) and authorize payments directly to Fredericksburg Orthopaedic Associates, P.C. Signature of Patient or Guarantor To Our Medicare Patients: Medicate requires that all Medicare patients read and sign the following before we can file your claim(s). I request that payment of authorized Medicare benefits be made on my behalf to Fredericksburg Orthopaedic Associates, P.C. for any services furnished me by their Physicians or Physician Assistants. I authorize any holder of medical information about me to release it to the Health Care Financing Administration (HFCA) and its agents and to my insurance company, any information needed to determine these benefits or the benefits payable for related services. Signature of Medicare Patient (Page 2 of 5)
PHYSICAL THERAPY REASON-TO-VISIT FORM Chart # Today s : Patient s Full Name: Sex: Male Female DOB: Age: Family Physician (PCP): Please list the part(s) of your body you will be receiving treatment on. Indicate Right or Left as appropriate. What physician first treated you for the above medical condition? of injury or of Onset of Complaint: Were you in an auto accident? Yes No In this a work-related injury covered by a Worker s Comp Claim? Yes No Describe in detail how you were injured; or if no injury, give a brief description of your complaint or pain. (Page 3 of 5)
PERSONAL MEDICAL HISTORY FORM After completing this form, print and sign at the bottom; and, provide to the receptionist when you check in. PLEASE ANSWER THE FOLLOWING QUESTIONS COMPLETELY 1. Check all that apply and explain the following medical problems that you have had: AIDS / HIV Drug Abuse Liver Disease Allergies Emphysema Motor Vehicle Accident Anemia Fainting Psychiatric Treatment Arthritis Fractures Rheumatic Heart Disease Asthma Glaucoma Seizures Back Trouble Heart Disease Shortness of Breath Bronchitis Heart Attack Sinusitis Cancer Heart Murmur Stomach Ulcers Chest Pain Hepatitis Stroke Congenital Heart Defect Herpes Swelling of Hands / Feet Convulsions High Blood Pressure Thyroid Disease Diabetes Kidney Disease Rheumatic Fever Bleeding Disease 2. List any operation or surgery that you have had: 3. Reasons for being referred to Physical Therapy: 4. List any medication you are currently taking: 5. List any allergies and describe any drug reactions: 6. Please check any of the following you may have / wear: Glasses Contacts Dentures Pacemaker Metal Foreign Object Implant 7. Are you pregnant? Yes No 8. Any significant weight gain / loss in the last year? Yes No ( ± ) lbs 9. Are you under the care of any other medical/health provider or physician? Yes No If Yes, for what condition are you being treated? 10. What do you expect to gain/accomplish in receiving physical therapy? TO THE BEST OF MY KNOWLEDGE, INFORMATION PROVIDED HEREIN IS CORRECT. Signature: : (Page 4 of 5)
PHYSICAL THERAPY TREATMENT POLICY The following is a brief explanation of our policies regarding physical therapy treatments. THIS PHYSICAL THERAPY DEPARTMENT IS PART OF FREDERICKSBURG ORTHOPAEDIC ASSOCIATES, P.C. IF YOU CHOOSE TO HAVE YOUR PHYSICAL THERAPY PERFORMED AT ANOTHER FACILITY, WE WILL BE GLAD TO REFER YOU. An itemized list of charges for your treatment will be given to you on your first visit to the therapy department. Payment in full will be expected at the time of each visit unless proof of full or partial insurance coverage for physical therapy has been furnished. If you have partial insurance coverage, you will be expected to pay the non-covered amount. If you cannot do this, arrangements must be made with our collection manager. In most cases, we will file your insurance for you or assist you with it. Please discuss this with our receptionist. We request notification of 24 hours prior to your appointment should you need to cancel. This allows us the opportunity to schedule another patient. If you have any questions or concerns, please discuss them with us so we can better serve you. I have read and understand the above policies. SIGNED: DATE: (Page 5 of 5)