The Movement Studio New Patient Intake Form

Patient Information
Full Name*

First Middle Initial Last
Date of Birth*

MonthDay Year
Male or Female?*

MaleFemale
Address*

Street Address

Street Address Line 2

City State

Zip Code
Home Phone*
Cell Phone
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact & Relationship*
Emergency Phone*
Physican Information
Referring Physician
Physician Phone Number
Please enter a valid phone number.
Appointment Policy
I understand that my doctor has prescribed therapy for me and that physical therapy is an on-going process that requires regular attendance to be optimally effective. I understand that if I am late for an appointment, I may have to reschedule my appointment or may have to accept an abbreviated treatment for that day. I understand that if I cancel or no show for three consecutive appointments, The Movement Studio has the right to discharge me from care for being non-compliant with my treatment plan. I understand and agree that The Movement Studio requires 48-hour advance notice of cancellation. If I fail to give 24-hour notice of cancellation or fail to show up for an appointment, I may be subject to a $75 charge (which is not covered by insurance).
Do You Agree? Please Initial.*
(Parent or Legal Guardian must initial if under 18 years of age)
Date*

MonthDay Year
Date
Relationship to Patient, if patient is under 18 years of age

MotherFatherLegal Guardian
Please send appointment reminders via

EmailText
Authorization for Treatment
I hereby consent to and authorize all therapy treatments, which in conjunction with the judgment of my attending physician, may be considered necessary and/or advisable for the diagnosis and/or treatment of the patient named above.
Do You Agree? Please Initial.*
(Parent or Legal Guardian must initial if under 18 years of age)
Date*

MonthDay Year
Date
Relationship to Patient, if patient is under 18 years of age

MotherFatherLegal Guardian
Financial Policy and Insurance Information
I understand and agree that insurance claim forms will be submitted to my insurance company as a matter of convenience only, and that I am personally responsible for all charges of all services provided. In the event that my insurance company denies benefits or makes a partial payment, I understand that I am responsible for the balance due. I hereby give authorization for payment of insurance benefits to be made directly to The Movement Studio for services rendered. In the event that my insurance company forwards payment directly to me, instead of The Movement Studio, I will immediately deliver said payment to The Movement Studio. I understand and agree that I am wholly responsible and liable for payment of all charges assessed for professional services rendered and will pay any sum due, upon demand. I understand and agree that if it becomes necessary for The Movement Studio to utilize an outside collection agency or to commence court action, for the collection of any outstanding charges, I will be responsible for the outstanding balance, and in addition, attorney fees, court costs, and other expenses of litigation.
Do You Agree? Please Initial.*
(Parent or Legal Guardian must initial if under 18 years of age)
Date*

MonthDay Year
Date
Relationship to Patient, if patient is under 18 years of age

MotherFatherLegal Guardian
Primary Insurance
How would you like to pay?*

Self Pay - CashInsurance
Name of Subscriber
Birthdate

MonthDay Year
Date
Relationship to Patient

SelfParentSpouseOther
Insurance Co & Subscriber ID #
Insurance Phone
Secondary Insurance
Do you have secondary insurance?*

YesNo
Name of Subscriber
Birthdate

MonthDay Year
Date
Relationship to Patient

SelfSpouseParentOther
Insurance Co & Subscriber ID #
Insurance Phone
Patient Medical History
Current Location of Pain
Date of Onset

MonthDay Year
Date
Check the box next to each option if you have (or recently had):*

None ApplyAllergiesAnemiaAnxietyArthritisAsthmaCancerCardiac ConditionsCardiac PacemakerChemical DependencyCirculation ProblemsCurrently PregnantDepressionDiabetesDizzy SpellsEmphysema/BronchitisFracturesGallbladder ProblemsHepatitisHigh Blood PressureIncontinenceKidney ProblemsMetal Implant(s)Multiple SclerosisOsteoporosisParkinsonsRheumatoid ArthritisSeizuresSpeech ProblemsStroke(s)Thyroid DiseaseTuberculosisVision Problems
Describe any other conditions or precautions:
Have you had any surgeries in the past?*

YesNo
Body Region
Surgery Type
Date
Body Region
Surgery Type
Date
Body Region
Surgery Type
Date
Body Region
Surgery Type
Date
Body Region
Surgery Type
Date
Current Medication
Are you currently taking any medicine?*

YesNo
If additional space is needed for listing medications, please bring a full list at the time of your appointment.
Drug Name
Dosage
Reason for Taking
Drug Name
Dosage
Reason for Taking
Drug Name
Dosage
Reason for Taking
Drug Name
Dosage
Reason for Taking
Drug Name
Dosage
Reason for Taking
Drug Name
Dosage
Reason for Taking
NOTICE OF PRIVACY PRACTICES

Review Only
The Movement Studio

Mary Gorman, PT

309 S Pacific Hwy

Talent OR, 97540

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. PLEASE REVIEW IT CAREFULLY.

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our facility and provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you.

By law, we are required to:
1. Keep your medical information private.
2. Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information.
We have the right to change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law. Any new information will be provided to you.

USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION

The following section describes different ways that we use and disclose medical information. Not every use of disclosure will be listed.

For Treatment: We may use your medical information for medical treatment of services. We may disclose medical information (ROI) about you to doctors, nurses, technicians, medical students, lawyers re MVA, or other people who are taking care of you.

For Payment: We may use and disclose your medical information for obtaining payment on our services.

For Health Care Operations: We may use your medical information to perform certain functions within our facility.

In addition to using and disclosing your medical information for treatment, payment, and healthcare operations, we may use and disclose medical information for the following purposes.

Client Database:

Unless you notify us that you object, the following medical information about you will be placed in our client database.
- Your Name
- Your Address
- Your Phone Number
Legal Issues:

We may disclose medical information in response to a court or administrative order, subpoena, discovery request, or other lawful processes. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials.

We may disclose medical information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or the possible victim of other crimes. Also if you are committing self-harm, child or elder abuse.

We may disclose medical information (ROI) when authorized and necessary to comply with laws relating to workers' compensation, MVA, or other similar programs.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION

You have the following rights regarding your health information which we create and/or maintain.
1. You have the right to review and copy medical information that may be used to make decisions about your care. You must request this information in writing. (If you request copies there will be a charge of $2/page + postage)
2. You have a right to know with whom we have shared your medical information.
3. You have a right to request restriction of uses and disclosures and communicating medical information.
QUESTIONS AND COMPLAINTS

If you have any questions about this notice, please contact our office. If you think that we may have violated your privacy rights, please contact our office. You may submit a written complaint to the US Department of Health and Human Services.

By signing below, you agree to the terms you have initialed, have reviewed the Notice of Privacy Practices, and have completed the above fields truthfully and to the best of your knowledge.
Signature of Patient or Guardian*

Clear
Patient Name (Print)*
Date*

MonthDay Year
Date
Patient Record Of Disclosures
In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI can be made by alternate means, such as sending correspondence to the individual's office instead of the individual's home.
Check all that apply in how you wish to be contacted:*

Cell/Mobile: OK to leave a message with detailed informationCell/Mobile: OK to leave a message with a call-back number onlyHome Phone: OK to leave a message with detailed informationHome Phone: OK to leave a message with a call-back number onlyOther
Patient Signature*

Clear
Date*

MonthDay Year
Date
Print Name*
Date*

MonthDay Year
Date
Should be Empty:

Patient Information

Physican Information

Appointment Policy

Authorization for Treatment

Financial Policy and Insurance Information

Primary Insurance

Secondary Insurance

Patient Medical History

Current Medication

NOTICE OF PRIVACY PRACTICES

Patient Record Of Disclosures