Back in Motion In-Clinic Patient Packet

Back in Motion In-Clinic Patient Packet

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Patient Information

Patient First Name

Initial

Patient Last Name

Date of Birth

(MM/DD/YYYY)

Phone Number

XXX-XXX-XXXX

Current Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Marital Status

SingleMarriedDivorcedWidow

Gender

MaleFemalePrefer not to answer

Clinic Location

Edit this text

Consent to Communicate by Email

By providing my email address, I understand that authorized personnel from this physical therapy practice may communicate with me regarding scheduling, treatment, health educational and promotional information.

Email Address

How did you hear about us?

DoctorInsuranceMailingEventGoogleFacebookReturning PatientFamily/Friend

Preferred Method of Contact

PhoneText/SMSEmailI do not consent to email communications

Preferred Language

EnglishSpanishOther

Do you need a translator?

YesNo

Is this visit injury related?

YesNo

If yes, please select type of injury.

WorkCar AccidentOther Liability/Potential Lawsuit

Employer Name

Employer Address

Street Address, City, State, and ZIP

Have you had any Physical Therapy anywhere else this calendar year?

YesNo

Where?

Number of visits completed?

Third Party Injury Liability Questionnaire

The nature of your injury may alert your medical insurance company to potential liability. Completing this form in its entirety allows the physical therapy company to provide a quick response to those inquiries and prevent delays in processing your claims.

Date of injury/onset of condition/recent exacerbation?

Describe in detail how the injury occurred

Who is responsible for the accident?

SelfOther

Insurance of Responsible Party

Claim #

Adjuster Name/Phone

Address

Please check the box below:

The above information is accurate and true to the best of my knowledge. I agree to immediately notify the Physical Therapy company with any change in this information.

Emergency Contact Information

First Name

Last Name

Relationship

Phone Number

XXX-XXX-XXXX

Authorization to Contact

I authorize permission to discuss only the following protected health information with my emergency contacts. Cancellation of this authorization must be submitted in writing.

Insurance Information

Billing Information

I am billing my insurance for these servicesI do not have insurance or I would rather pay directly

Do you have Medicare?

YesNo

Are you enrolled in Home Health?

YesNo

Name of Agency/Nurse/Therapist:

Phone Number

Primary Insurance Company

Policy #

Group #

Policy Holder Name

(Name of insurance policy owner)

Policy Holder Date of Birth

(MM/DD/YYYY)

Relationship to Patient

Secondary Insurance Company

Secondary Policy #

Policy Holder Name

(Name of insurance policy owner)

Policy Holder Date of Birth

(MM/DD/YYYY)

Relationship to Patient

Please upload the front of your insurance card

Please upload the back of your insurance card

Please upload your photo ID/Driver's License

Medicare Secondary Payer (Only complete if you are enrolled with Medicare)

As a direct result of mandated Medicare Secondary Payer (MSP) regulations, we are required to gather the following information to determine if Medicare is your primary insurance.

Is the illness/injury due to an automobile accident, liability accident or Worker’s Compensation?

YesNo

Is illness covered by the Black Lung Program or Veterans Administration program?

YesNo

If under 65, are you a renal dialysis patient within the first 30 months of Medicare entitlement?

YesNo

If under age 65, disabled, and covered under an employer’s Group Health Plan, does the employer have more than 100 employees?

YesNo

If 65 and over, are you or your spouse employed by a company that has more than 100 employees and are you covered by their Group Health Plan?

YesNo

Have you received / are you receiving healthcare services from one of the following:

Skilled Nursing FacilityHome Health AgencyNone

Date Discharged:

Do you have a copy of your discharge letter?

YesNo

Home Health Agency

Phone Number

Patient Health Questionnaire

Height

Weight

Referring Physician

Upload Referral from Referring Physician

What problem(s) are you being treated for today? When and how did they start?

Have you had surgery for this injury?

YesNo

Pain Assessment - Please report a pain assessment on the scale below where 0 is no pain and 10 is the worst pain imaginable.

012345678910

FUNCTIONAL PROBLEMS (Please list any and all functional problems you currently have due to your diagnosis)

Is there anything else we should know that is pertinent to your treatment?

Have you had any of the following medical or rehabilitative services for this injury/episode?

ChiropractorCT ScanEmergency Room CareGeneral PractitionerMassage TherapyMRINeurologistOccupational TherapyOrthopedistPhysical TherapyX-RaysOtherNone

Have you ever had any of the following? (Please select all that apply)

None	Allergies
Anemia	Are you pregnant?
Arthritis/Swollen Joints	Blood Clot/Emboli
Cancer or Chemotherapy/Radiation	Coronary Heart Disease or Angina
Diabetes	Dizziness or Fainting
Do you smoke?	Emotional/Psychological Problems
Epilepsy/Seizures	Heart Attack
High Blood Pressure	Infectious Disease
Numbness or Tingling	Osteoporosis
Pacemaker or Defibrillator	Shortness of Breath/Chest Pain
Sleeping problems/difficulties	Stroke or TIA
Vision or Hearing Difficulties	Weakness
Weight Loss/Energy Loss	Other

Have you had any recent or major surgery?

YesNo

If yes, please describe below:

Are you taking any prescription or non-prescription medications?

YesNo

If yes, please list medications or upload below:

Upload Medications List

Do you have a history of falls?

YesNo

If yes, when was the last fall? Was there an injury?

Please list any allergies (i.e. latex, adhesives, etc)

Foot Orthotics Questionnaire

Are you interested in learning more about how foot orthotics may help you in your rehabilitation?

Please note: If you select 'Yes', your information will be forwarded to our trusted partner, Biocorrect Custom Foot Orthotics, to get in touch with you for further information or to answer any questions you may have.

Consent and Statement of Financial Responsibility

I hereby consent to the use and disclosure of my health information for treatment provided to me by this physical therapy practice, payment for services provided by the provider or other health care providers and the operations of this physical therapy practice and others under certain circumstances. I understand that a more detailed explanation of the ways this physical therapy practice may use and disclose my health information is contained in the Notice of Privacy Practices of the Provider, a copy of which has been provided to me.

PATIENT CODE OF CONDUCT

It is our goal to provide the highest quality of care in a safe environment. In our efforts to achieve this goal, we require all patients and visitors to refrain from any behavior that may pose a threat to the rights or safety of other patients and employees. Our patients agree to refrain from the following actions: (1) Bringing firearms or other weapons into the clinic; (2) Inappropriate behavior involving alcohol/substance use at time of treatment; (3) Attempting to intimidate or harass in any manner therapists, staff, or fellow patients; (4) Inappropriately touching therapists, staff, or fellow patients; (5) Racial or cultural slurs or other derogatory remarks associated with, but not limited to, race, language or sexuality; (6) Making verbal threats to harm another individual or destroy property through any medium of communication; and (7) Physical assault or inflicting bodily harm. Violators of the abovementioned actions may be asked to leave the facility and/or be discharged from the clinic. My signature below indicates that I will support the clinic in its efforts to provide me with quality care in a safe environment and that I understand and accept the terms of the Patient Code of Conduct.

Please check indicating you have read the above statement.

I have read the above statement.

CONSENT FOR TREATMENT

I hereby consent to physical or occupational therapy services deemed medically necessary by my therapist and other health care professional involved in my care. I understand that my physical therapy program may include remote therapeutic monitoring (RTM). RTM services include telephone or video communications from a clinician to review my progress between in-clinic visits. This communication will allow my therapy team to monitor my progress and adjust my home exercise program as necessary to achieve my rehabilitation goals. I will receive complimentary access to the MedBridgeGo© software as well as education to use the app throughout my course of care.

Please check indicating you have read the above statement.

I have read the above statement.

CANCELLATION AND NO SHOW POLICY

Patients are expected to keep all scheduled appointments to maximize the benefits of their treatment plan. If a patient is unable to make a scheduled appointment, the patient is expected to give 24 hours advance notice or may be charged a cancellation fee of $60. Two (2) consecutive appointment no-shows may result in discontinuation of the current appointment schedule for the therapy involved. A pattern of frequent absences (cancellation and/or no-shows) will be considered problematic and result in discontinuation of services.

Please check indicating you have read the above statement.

I have read the above statement.

TELEPHONE CONSUMER PROTECTION ACT NOTICE

You expressly consent and agree that, in order to discuss or provide services for your account(s) (the "Accounts") or to collect amounts you may owe, this Physical Therapy Practice, and its officers, agents, affiliates, employees, first and third party debt collection agencies, and any affiliated or business associated service providers or vendors of any of these parties, associated therewith (collectively, "We") may contact you by telephone at any telephone number associated with the Accounts, including wireless telephone numbers, which could result in charges to you. You confirm that any telephone number provide is associated with you and not a third-party. You expressly consent and agree that We may also utilize your information to contact you by letters or notices via mail, by sending emails, using any e-mail address you provide to us, by sending text messages or by pre-recorded or artificial voice or voice messages, via predictive or automatic dialing methods, systems, or devices, and pre-recorded or artificial voice announcements or prompts at any telephone number associated with the Accounts, including landlines, wireless or mobile telephone numbers, regardless of whether you incur charges as a result.

Please check indicating you have read the above statement.

I have read the above statement.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

You may access a copy of the Notice of Privacy Practices upon request or by downloading on the company website.

Please check indicating you have read the above statement.

I hereby acknowledge that I have received the Notice of Privacy Practices of this physical therapy practice.

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