WC /NEW PATIENT INTAKE FORM

PATIENT INFORMATION

NAME

DATE OF BIRTH

ADDRESS

HOME PHONE

MOBILE

WORK PHONE

EMAIL ADDRESS

AUTHORIZED TO LEAVE MESSAGE:

HOME

MOBILE

WORK

PRIMARY CARE OR REFERRING DOCTOR:

HAVE YOU HAD PHYSICAL THERAPY IN 2024

YES NO

HOW MANY?

EMPLOYER:

ADDRESS:

PHONE #:

BILLING INFORMATION

HEALTH INSURANCE SELF PAY WORKER’S COMP MVA

(MUST HAVE MEDPAY WITH YOUR INSURANCE)

OTHER

INSURANCE COMPANY:

ID #

NAME OF INSURED, IF OTHER THAN PATIENT

RELATIONSHIP

DATE OF BIRTH

SECONDARY INSURANCE:

ID #

NAME OF INSURED, IF OTHER THAN PATIENT

RELATIONSHIP

DATE OF BIRTH

MVA DATE OF INJURY:

W/C DATE OF INJURY:

CLAIM #:

ADJUSTOR:

PHONE #:

COMPANY:

ADDRESS:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Signature of Patient or Legal Guardian:

DATE OF BIRTH

Please provide your doctor and/or physical therapist with a complete list of any prescriptions, over the-counter medicine, herbals, and vitamin/mineral/dietary (nutritional) supplements you are presently taking. Please notify our staff if you make any changes.

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Signature of Patient or Legal Guardian:

DATE OF BIRTH

General Policies

I,(Please input Name below) authorize the staff of Team Rehab, P.C. to perform such procedures as may be deemed necessary for me or my minor child.

Initial

I authorize Team Rehab, PC to release information necessary to process this claim to my health insurance carrier, Medicare, Workers Compensation, and Auto. I hereby assign to Team Rehab, P.C. all payments for medical services rendered to me or my dependents

Initial

I understand that Team Rehab, P.C. will assist in obtaining prior authorization for medical treatment. Team Rehab, P.C. is not responsible to know or keep current with the status of your copay, deductible, co-insurance, and requirements such as referrals or prior authorization. Any gaps in authorization or non-payment of services for which Team Rehab can legally transfer the balance to the patient will be my responsibility to pay. This includes denials of payment due to reaching my maximum benefit limit, Med Pay exhaustion, Medicare Therapy Threshold when a signed Advanced Beneficiary Notice has been obtained, and other denials unrelated to routine contractual adjustments between Team Rehab and your carrier.

Initial

Your Insurance Plan contract is an agreement between you and your insurance company. We recommend that you contact your Insurance Company if you have an questions about the accuracy of the information our insurance specialists have received.

Initial

FINANCIAL POLICY

l Copays/Late Payments: I understand that all copays and deductibles will be paid at the time of the service. If payment is not received at the time of the service, a $10 charge will be added to the copay/deductible amount for each date of service. Each month, I will receive a statement of services which is due and payable within 30 days of services rendered. If my payment is late and I do not communicate with the billing staff, an interest charge will accrue at the rate of 1.5% per month beginning 60 days following the date that services were rendered. After 90 days, my account will be placed in collections, and I am responsible for any court costs and related collection fees incurred.

Initial

Insurance Card: I understand that if I do not present my insurance card or Team Rehab is unable to verify my coverage, I am responsible for the payment of services rendered to me.

Initial

Insurance Coverage: I understand that if my insurance terminates or changes during my treatment and I do not notify Team Rehab in a timely manner, I am responsible for payment of the visits during the non-coverage period.

Initial

Returned Checks: : I understand that all returned checks will be subject to an additional $25.00 service fee.

Initial

Missed Appointments: I understand that I am responsible for any missed appointments that were not cancelled within 24 hours. I am aware that Team Rehab charges $50.00 for follow up physical therapy visits, and $75.00 for new evaluations. Physician visits are charged at $75.00 for follow up visits and $125.00 for new evaluations.

Initial

If you meet your maximum benefit limit, or your insurance does not authorize additional visits, or you do not have insurance, we offer a self-pay rate for Physical Therapy with a fee for an Initial Evaluation of $125.00, a Re-evaluation of $90, and a follow-up visit of $75.00. Physician self-pay rates for New Patient visits range from $200-$450 depending on the level of complexity, and $100-$250 for Established Patient visits.

Initial

Our office does not participate in Medicaid or Husky. We do not accept it as your primary or secondary insurance. While our office encourages you to find a participating provider, you have opted to receive services at Team Rehab and understand you are responsible for payment at our self-pay rate at the time of service.

Initial

I hereby have read and understand the Financial Policy. I guarantee payment of all charges incurred for me/my minor child’s account.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Signature of Patient or Legal Guardian:

Date:

PATIENT AUTHORIZATION FORM

Authorization to Release Information to Family Members

Many of our patients allow family members such as their spouse, significant other, parents or children to call and request the result of tests, procedures, and financial information. Under the requirements of H.I.P.A.A., we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical information, any diagnostic test results and/or financial information released to any family members, you must sign this form.

You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on n your prior consent.

I authorize Team Rehab, P.C. to release my records and any information requested to the following individuals.

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Authorization Regarding Messages

(Please check all that apply)

I authorize you to leave a detailed message on my home or cell number regarding appointments.

I authorize you to leave a detailed message on my home or cell number regarding medical treatment, care, test results or financial information.

I authorize you to leave a message with anyone who answers the phone.

Messages may only be left

with:

Date:

ACKNOWLEDGEMENT OF HIPAA PRIVACY PRACTICES

I acknowledge that I have reviewed and understand the HIPAA policies on our website and or our office waiting room and I understand that I may request a copy if I so choose.

Patient Signature:

Date:

Print Name:

Date of Birth:

AUDIO/VIDEO ACKNOWLEDGEMENT

Please be advised, that in order to better enable us to assure compliance with HIPAA privacy and security laws and regulations, and in recognition of the legitimate privacy concerns of our patients and staff, the use of any audio or video recording devices in this office by patients or other visitors, including but not limited to cell phones, is strictly prohibited.

We reserve the right to terminate any patient as permitted under State law if the patient or anyone accompanying the patient is found to be in violation of this policy. We appreciate your understanding and cooperation.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Patient Signature:

Date:

Welcome to Team Rehab. The purpose of this questionnaire is for your therapist to better understand your problem(s). Please answer the following questions to the best of your ability. Thank you!

General Health

1. Have you had any illnesses within the last 3 weeks (e.g. colds, influenza, bladder or kidney infection)? If yes, please list

Yes No

2. Have you noticed any lumps or thickening of skin or muscle anywhere on your body?

Yes No

3. Have you had any unexplained weight gain or loss in the last month?

Yes No

4. Do you smoke or chew tobacco?

Yes No

If yes, how many pack/day?

For how many months or years?

5. Do you have a pacemaker, transplanted organ, or metal implants?

Yes No

If yes, explain

6. Height

Weight

Please see attached sheet for Medication Information

1. Have you had any x-rays, sonograms, computed tomography (CT) scans, magnetic resonance imaging (MRI), or lab work done recently?

Yes No

2. Please list any previous operations and the date(s):

Operation / Date

Work Environment

1. Occupation:

2. Does your job involve:

Prolonged sitting (e.g. desk, computer, driving)

Prolonged walking (e.g. mill worker, delivery service)

prolonged standing (e.g. sales clerk)

Lifting, bending, twisting, climbing, turning

3. Do you use any special supports:

back cushion, neck cushion

back brace, corset

other kind of brace or support for any body part

4. History of falls:

I have no falls

I fall occasionally

I have just started to lose my balance/fall

Certain factors make me cautious (e.g. curbs, ice, stairs)

To better understand your symptoms, please answer the following questions as best as possible:

Indicate in the diagram where you feel your symptoms

Describe your current symptoms (e.g. sharp, achy, etc.)

Did your symptoms begin due to a specific event?

car accident

fall

slowly without injury

work related

If other, please describe:

Have your symptoms changed since the initial onset or injury?

Yes No

If yes, please describe

Please list things that make you feel better (e.g. activity, positions, ice, heat, etc.)

What aggravates your symptoms?

Visual Analog Scale

Please rate your pain using the pain scale below:

Now

Average Pain

Worst Pain

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Signature of Patient or Legal Guardian:

Date:

Your information will be encrypted.