Deac West Registration

PATIENT REGISTRATION
DATE

MonthDayYear
Date
LAST NAME*
LAST NAME*
FIRST*
FIRST*
M
Address*

Street Address

Street Address Line 2

CityState

Zip Code
SSN
DOB*

MonthDayYear
Date
PRIMARY PHONE NUMBER*
PHONE TYPE*
IS INJURY RELATED TO:*

WORKAUTOOTHER
IS A HOME HEALTH AGENCY CURRENTLY PROVIDING NURSING SERVICES IN YOUR HOME?*

YesNo
HAVE YOU HAD ANY THERAPY SERVICES IN THE LAST 12 MONTHS?*

YesNo
EMERGENCY CONTACT NAME*
RELATIONSHIP*
PHONE NUMBER*
If using a smart phone or tablet with a camera, please take a clear and complete photo of your driver's license.

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IS SOMEBODY OTHER THAN THE PATIENT FILLING THIS FORM OUT*

YESNO

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

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

MonthDayYear
Date
PHONE TYPE*
PHONE #*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

EMPLOYER INFORMATION
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.

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

MonthDayYear
Date
CLAIM #
NUMBER OF VISITS APPROVED

Payment at Time of Service
As a standard practice, Deaconess Hospital, Inc.’s Physical Medicine Department 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, Deaconess Hospital, Inc.’s Physical Medicine Department 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.

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.

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.
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 $20 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. Thank you for your consideration.

You are not required to sign the agreement (directly or indirectly), or agree to enter into such agreement as a condition of purchasing any property, goods or services.

By signing below, I understand and agree to the terms of the above Payment at Time of Service Policy and Cancellation/Noshow Policy.
Date

MonthDayYear
Date
PRINTED NAME*
SIGNATURE OF PATIENT/GUARDIAN*

Clear

INFORMED CONSENT
I consent to treatment rendered by Deaconess Hospital’s Physical Medicine Dept. as ordered or approved by my physician. I agree to participate in Deaconess Hospital’s Physical Medicine Dept. program to the best of my ability to facilitate a rapid and full recovery.

I consent to having my picture taken for objective analysis of my condition. This information will be used solely for the purpose of education of myself for my condition and to compare pre and post treatment outcomes. Any other use of this information will require my
written consent.

I understand that some increase in pain may be normal. I must determine how much pain increase is acceptable to me, and I may be asked to describe any pain using a Visual Analog Scale. I will not be asked to perform activities that increase my pain to a level that is unsafe or undesirable to me. I will be asked to perform activities, but will not be forced to perform any activity that I believe unsafe. I will be informed if I’m seen doing anything unsafe or that jeopardizes my recovery.

given at the time of service are not a guarantee of payment. I assign all benefits paid by insurance to be paid directly to Deaconess Hospital’s Physical Medicine Dept. By my signature below I acknowledge my responsibility and assign said benefits and verify that I have read and agree to the terms of the Deaconess Hospital’s Physical Medicine Dept. Payment Policy.

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

MonthDayYear
Date
Signature*

Clear

FINANCIAL RESPONSIBILITY
Thank you for choosing Deaconess. Our goal is to provide you with quality medical services. Your clear understanding of our financial policy is important to our professional relationship. PLease understand that payment of your bill is vital to our ability to continue to provide medical care within the community. We accept Cash, Check, Visa, MasterCard and Discover.

ALL ACCOUNTS

In consideration of Deaconess Hospital, Inc. and/or its affiliated entities, including but not limited to Deaconess Clinic, Inc., (collectively "Deaconess") rendering services for the above named patient, I/we, the undersigned, and each of us, agree to be jointly and severally responsible for payment for this hospitalization and any other account that the patient had at any time in the past, at the present, or may have in the future with Deaconess. I/we agree that the charges for which I/we are responsible will be calculated according to Deaconess's Chargemast and I/we agree to pay those Chargemaster rates. All accounts are due and payable at the time of the patient's discharge. Any credit will be applied to outstanding balances prior to being refunded. Please contact the Deaconess Financial Counselling Services at 812-450-6815 if you need assistance. Past due patient accounts that do not have agreed upon financial arrangements with Deaconess will be submitted to a collection agency or attorney for collection. I/we agree that I/we will pay all attorney feeds and court costs incurred by Deaconess in the collection of all sums due Deaconess. If I/we provide Deaconess or its agents with our cell phone number, I/we authorize Deaconess or its agents to call our cell phone either manually or by auto-dialer in order to collect any amounts I/we owe. I/we understand that any e-mail I/we provide is our personal e-mail and I/we authorize Deaconess or its agents to contact us via that e-mail address.

WORKER'S COMP / LIABILITY / AUTO ACCIDENT

If the reason for your visit is related to a workers comp claim, liability claim, or auto accident, you are responsible for providing Deaconess with complete billing information, including police report, claim number, etc. as appropriate, within seven (7) business days. You should be aware that if you do not provide this information or these claims are denied, the balances then become the patient's repsonsibility.

INSURANCE

If the patient has active insurance coverage, we will bill the patient's insurance company. It is the patient's responsibility to understand his/her insurance coverage. You will receive a monthly statement if your account has a patient due balance. Payment of deductibles, non-covered services and co-payments are your responsibility.

ASSIGNMENT OF INSURANCE BENEFITS

I/we assign insurance payments to be made directly to Deaconess for services rendered.

I/we have read, understand and agree to the terms listed above.

NOTICE OF NONDISCRIMINATION

I have received a Notice of Nondiscrimination.
Date

MonthDayYear
Date
Printed Name*
Printed Name
Signature*

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AUTO INSURANCE
AUTO INSURANCE COMPANY
ACCIDENT OCCURRED IN WHICH STATE?*
Date

MonthDayYear
Date
CLAIM/POLICY #
ADJUSTOR/AGENT
ADJUSTOR/AGENT PHONE #
CHECK ALL THAT APPLY

PASSENGERDRIVEROTHER

AUTHORIZATION FOR DISCLOSURE
I, a patient of Deaconess Hospital’s Physical Medicine Dept., give my expressed permission to discuss with the individual(s) I have listed:
Please check appropriate box(es):

Any aspect of my health careHealth information onlyFinancial information only
Name
Relationship
Phone
Name
Relationship
Phone
Name
Relationship
PATIENT NAME
Signature

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Date

MonthDayYear
Date
Phone

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

WORK RELATED INJURY

MEDICAL HISTORY QUESTIONNAIRE

Medicare Secondary Payer Questionnaire

APPOINTMENT REMINDER CONSENT

Payment at Time of Service

Cancellation / No-Show Policy

INFORMED CONSENT

FINANCIAL RESPONSIBILITY

AUTO INSURANCE

AUTHORIZATION FOR DISCLOSURE

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT