Patient Intake (2)

Patient Intake
Primary Clinic *

Boulder Broomfield Englewood Lafayette Longmont Wheat Ridge
How did you hear about us? *

Online Previous Patient Referring Physician Family/Friend Insurance Provider
Physical Therapist
Name *

First Name Last Name
Date of Birth *

Month Day Year
Phone Number *
Phone Type *

Mobile Home
Email
example@example.com
Preferred contact method *

Phone Email
Are you a returning patient? *

Yes No
Has any of your information changed?

Yes No
Address *

Street Address

Street Address Line 2

City State

Zip Code
Emergency Contact

Name Relationship Phone Number
Insurance *
Would you like to provide your insurance information?

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Insurance Card

Browse Files
Please upload both the front and back Cancel of
Date of onset/injury

Month Day Year
Date
Referring Physician
(If applicable)
Please explain your injury *
Are you currently experiencing pain? *

Yes No

Have you had a related surgery? *

Yes No
If yes to the above, what surgery?
Date of Surgery

Month Day Year
Date
Check any of the conditions that may apply: *

Asthma Blood Pressure Cancer Diabetes Pregnant Recent Fracture Chest Pain/Angina Pacemaker Stroke Diabetes Osteoporosis Traumatic Brain Injury Heart Disease Seizures None of the above
Are you currently taking medications? *

Yes No
Please list medications here

Notice of Health Information Practices (HIPPA)

This notice describes how information about patients may be used and disclosed, in addition to how patients can access this information.

Introduction

Altitude Physical Therapy uses personal health information of patients responsibly. How and when we collect and use this information is explained in this notice. Patients' rights are also explained. This notice is consistent with all federal regulations.

Understanding Health Records/Information

All patient visits are documented in a chart. Patients' comprehensive medical history and subjective information, objective findings and assessment, diagnostic information and future plan of care are included. Verbal and written communication with other health care practitioners is also documented. This information can possibly serve as a:
- Means of communication between health care providers who share in the care
- Basis for planning care and treatment
- Legal document describing the care received
- Means by which you or a third-party payer can verify that services billed were actually provided
- A source of data for our planning and marketing
- A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve
This information should help you, the patient, to understand who, what, when and why others may access your information. Also, you can make informed decisions when authorizing disclosure to others.

Your Health Information Rights

Your medical records are the physical property of Altitude, however, the information in it belongs to you. You have the right to:
- Obtain a paper copy of this notice of information practices upon request
- Inspect and copy the health record (we ask for a 24 hour request)
- Obtain a list of the disclosures of your health information
- Revoke your authorization to use or disclose health information except to the extent that action has already been taken
Our Responsibilities

Altitude is required to:
- Maintain the privacy of the health information
- Provide patients with this notice as to our legal duties and privacy practices with respect to information that we collect and maintain
- Abide by the terms of this notice
- Notify the patients if we are unable to agree to a requested restriction
We reserve the right to change our practices in order to maintain compliancy with updated federal guidelines. These changes will be made available to each patient when returning for a follow-up visit.

We will not use or disclose health information without authorization, except as described in this notice. We will also discontinue to use or disclose health information after we have received revocation of the authorization.

We will provide health information wihout authorization when necessary for treatment, payment or healthcare operations.

Appointment Notification: We may contact you on the telephone or by email to provide appointment reminders and to follow-up with you after treatment in our facility.

Worker's Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Correctional institutions: Should a patient eventually become an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for healthcare and the health and safety of other individuals.

Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpeona (e.g. child protection, etc.)

Federal law makes provision for heath information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.

For more information or to report a problem

If you feel your privacy rights have been violated or you would like more information, you can contact our Privacy Officer, or the Office for Civil Rights, U.S. Department of Health and Human Services.
Please include a list of others' who you are authorizing to have access to your medical information:

Patient Financial Responsibility

The patient (or patient's guardian if a minor) is ultimately responsible for the payment for his or her own treatment and care. Altitude PT will attempt to contact and verify coverage for you prior to your visit as a courtesy. However, it is not always possible to do so. The patient is required to provide us with the most correct and updated information about his or her insurance, and will be responsible for any charges incurred if the information provided is not correct or updated. We will not accept insurance if patients' address or information is not updated at the time of visit.Patients are responsible for the payment of copays, coinsurance, deductibles and all other procedures or treatment not covered by their insurance plan. Payment is due at the time of service, and for your convenience we accept cash, check and most major credit cards at our office.If you have waived insurance billing and have registered as a cash/private pay patient you agree that at the time of service you will be paying by cash, check or credit card. Due to this cash payment you are receiving a discount. We will not bill insurance for services provided under this arrangement. No forms will be produced now or in the future for you or us to submit for insurance billing. Cancellation/No Show Policy: Your therapist will recommend a specific treatment plan including a specific number of treatments per week. Attending all of these visits is crucial to your rehabilitation. Missing these appointments will only slow your recovery. Appointment "no shows" or last minute unexcused cancellations will not only slow your recovery down, but will also negatively impact our other patients who are looking for convenient appointment times. We will make every effort to be as flexible as we can to schedule appointments at times that are convenient for you. Please return this courtesy by attending all scheduled appointments.

1st no show/less than 24 hr cancel - no charge

2nd no show/less than 24 hr cancel - $50 charge will be assessed

**For patients with Medicaid or VA insurance, please note the specific cancellation and no-show policy agreement

Do you have Medicaid or VA? *

Yes No
Medicaid/VA Cancellation and No-Show Policy Agreement

A total of two no-shows may result in a discharge from physical therapy. You will be required to revisit your physician and obtain a new referral in order to continue therapy.

Disclaimer: Some Medicaid plans are switching to Denver Health. Please let us know if you receive notification of your plan changing.

COVID-19 Liability Release Waiver

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and local health departments have recommendations in place. I further acknowledge that Altitude Physical Therapy and Sports Medicine (hereafter referred to as “Altitude”) has put in place preventative measures to reduce the risk of contracting the Coronavirus. I understand that, while the risk is small due to preventative measures in place, there is a risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 resulting from direct or indirect contact with others at Altitude. I voluntarily seek services provided by Altitude and acknowledge that there is an option to utilize telemedicine instead. I acknowledge that I must comply with all set procedures to reduce the spread while attending all current and future appointments.
I attest that: *

I am not experiencing any symptom of illness such as fever or chills, cough, shortness of breath or difficulty breathing, fatigue, sore throat, nausea or vomiting, diarrhea or new loss of taste or smell. I have not traveled to a highly impacted area within the United States or internationally in the last 14 days I do not believe I have been recently exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19 I have not been diagnosed with Coronavirus/COVID-19 OR I have been diagnosed in the past, but I have since been cleared by a medical provider to end isolation or it has been more than 14 days since diagnosis and I have no current symptoms. I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19
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