EastRegistration

RESPONSIBLE PARTY ( IF OTHER THAN PATIENT)
NAME ( PARENT/ GUARDIAN/ OTHER, WHO BROUGHT MINOR FOR THERAPY)*

First NameLast Name
RELATIONSHIP TO PATINET*
RELATIONSHIP TO PATINET*
SSN*
DOB*

MonthDayYear
Date
HOME PHONE
WORK PHONE
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CELL PHONE

EMPLOYER INFORMATION
EMPLOYER NAME
EMPLOYER ADDRESS

Are you a self pay patient?*

YesNo

MEDICAL INSURANCE INFORMATION
POLICY HOLDER NAME*
PATIENT RELATIONSHIP TO SUBSCRIBER*
DO YOU HAVE MEDICARE?*

YESNO
INSURANCE NAME*
MEMBER ID/POLICY #*
GROUP #
EFFECTIVE DATE*

MonthDayYear
Date
If using a smart phone or tablet with a camera, please take a clear and complete photo of your insurance card.

Browse Files

Cancelof

AUTO INSURACE INFORMATION
INSURANCE NAME*
INSURANCE PHONE*
DATE OF ACCIDENT*

MonthDayYear
Date
POLICY #*
CLAIM #
ADJUSTOR/AGENT*
AGENT PHONE #*
AGENT FAX #

WORK RELATED INJURY
EMPLOYER NAME*
EMPLOYER ADDRESS*
CASE MANAGER NAME*
CASE MANAGER PHONE #*
EMPLOYER LIABILITY CARRIER*
LIABILITY CARRIER ADDRESS
DATE OF INJURY*

MonthDayYear
Date
NUMBER OF VISITS APPROVED*

FINANCIAL RESPONSIBILITY
Assignment of Benefits
ProgressiveHealth of Indiana will file my insurance claims as a courtesy, and I understand that any quoted benefits provided at the time of service are not a guarantee of payment. I assign all insurance benefits to be paid directly to ProgressiveHealth of Indiana. I understand that I am ultimately responsible for the charges incurred for my services at ProgressiveHealth of Indiana that are not covered by my insurance.

I understand that additional information may be required of me to assist ProgressiveHealth of Indiana in filing such claims, and I agree to provide this information as requested, including by not limited to:

o Social Security Number

o Date of Birth

o Copy of Insurance Card (for commercial filing and/or workers’ compensation)

o Name of employer, employer address, phone number and contact person

o Auto Insurance
Payment at Time of Service
As a standard practice, ProgressiveHealth of Indiana collects all expenses that are the responsibility of the patient at the time of service. This request for payment will include any deductible, co-pay and coinsurance amounts that apply to my visit. I understand that as a courtesy, ProgressiveHealth of Indiana will bill my insurance directly for the services I receive, but this is not a guarantee that my insurance will pay for services rendered or materials received. It is my responsibility to know my insurance benefits and coverage.

In some cases, the amount of charges is an estimate based upon information provided directly by my insurance company regarding my particular plan and eligibility and the procedures performed. However, the exact amount of all charges may not be known at the time of service as my insurance may process differently than anticipated. It is possible that additional expenses that are my responsibility may be reflected on my final statement. In such a case, the payment collected at the time of service serves as a deposit towards my final balance. Additionally, any overpayment will be promptly refunded to me after all claims have been processed by all applicable payers.

In the event that there is a past due balance on my account, it will be submitted to a collection agency, and I agree to pay all attorneys’ fees and court costs incurred by ProgressiveHealth of Indiana in the collection of my account.

I understand that if I anticipate problems paying my portion of my bill, I should let the Front Office Coordinator know as soon as possible, so that payment alternatives may be discussed, should I qualify.

I authorize ProgressiveHealth of Indiana or its agents to contact me via manual or auto-dial telephone call in order to collect any amounts I may owe, including calls to my cell phone number, if I have provided that number. I also agree that any email address I have provided is my personal email address and I authorize ProgressiveHealth of Indiana or its agents to contact me via that email address.

I acknowledge that I have read, understand, and agree to all of the terms above.
Date

MonthDayYear
Date
PRINTED NAME*
SIGNATURE OF PATIENT/GUARDIAN*

Clear

CANCELLATION / NO-SHOW POLICY
We strive to provide not simply good, but absolutely the best care to our clients. We schedule our clients according to care plans that optimize their wellness outcomes. Making your appointment as scheduled is very important, not just for us, but for you. We are convinced that if you make your wellness a life priority, you will achieve not only a higher level of function, but a greater degree of happiness.

We have the most highly trained and experienced clinicians in the region. You are working with the best. Their services and time are in high demand, with waiting lists for many of their services. As you know, we attempt to schedule all new clients within 24-48 hours of their initial request for service. Thus, appointment time is a valuable commodity for both you and us.

If negative circumstances require you to cancel a scheduled appointment, we request that you do so at least 48 hours in advance. If you must cancel within 24 hours of your appointment or fail to show up for your appointment, a $25 fee will be applied to your account, which will be patient responsibility and is not billable to insurance. This facility also reserves the right to cease rescheduling new appointments due to habitual no shows or cancellations and reserves the right to discharge any patient who fails to give proper notice three consecutive times.
While we are not fond of the negative connotation of any cancellation policy, we believe such a policy is in the best interest of accommodating all of our clients who are dedicated to improving their wellbeing. When an appointment is made, it takes an available slot away from another client. No-shows and late-cancellations prohibit us from offering that slot to another client. We understand that situations such as medical emergencies occasionally arise when an appointment cannot be kept and adequate notice is not possible. These situations will be considered on a case by case basis. Thank you for your consideration.

I acknowledge that I have read and understand the Cancellation / No-Show Policy.
Date

MonthDayYear
Date
PRINTED NAME*
SIGNATURE OF PATIENT/GUARDIAN*

Clear

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
Click here for the Notice of Privacy and Practices
I have received a Notice of Privacy Practices from ProgressiveHealth of Indiana.
Date

MonthDayYear
Date
Signature*

Clear
Should be Empty:

	Yes	No
Cancer
Chest Pain or Shortness of Breath
Heart Disease
High Blood Pressure
Pacemaker
Heart Attack
Stroke or TIA
Congestive Heart Disease
Blood Clots
Circulation Problems
Seizure Disorder or Epilepsy
Thyroid Problems
Asthma, Emphysema or Bronchitis
Chemical Dependency
Diabetes
Rheumatoid Arthritis
Other Arthritis Conditions
Infectious Diseases
Hepatitis
Headaches Frequent/Severe
Hearing/Vision Difficulties
Numbness or Tingling
Dizziness
Weakness

	Yes	No	Type
Neck
Back
Shoulder
Elbow
Hand
Hip
Knee
Ankle

PATIENT REGISTRATION

RESPONSIBLE PARTY ( IF OTHER THAN PATIENT)

EMPLOYER INFORMATION

MEDICAL INSURANCE INFORMATION

AUTO INSURACE INFORMATION

WORK RELATED INJURY

MEDICAL HISTORY QUESTIONNAIRE (PLEASE PRINT)

INFORMED CONSENT

AUTHORIZATION FOR DISCLOSURE

APPOINTMENT REMINDER CONSENT

FINANCIAL RESPONSIBILITY

Assignment of Benefits

Payment at Time of Service

CANCELLATION / NO-SHOW POLICY

Medicare Secondary Payer Questionnaire

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT