PT Revolution Intake Form

Physical Therapy Patient Intake Form

We Look Forward to Getting You Back in Action!
What is your primary goal with physical therapy?
E-mail
Personal Information
Name *

First Name Last Name
Age *
Sex

Male Female
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Employer Name
Occupation
Emergency Contact
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Relation
Payment Information
I intend to pay for my physical therapy services with: *

Cash Insurance Worker's Compensation Coverage Lien
Best thing here is to upload pics of the front and back of your insurance card. If you do that, you can skip entering all the details below (except member birthday :)!!!
Front of Insurance Card (Primary)

Browse Files

Cancel of
Back of Insurance Card (Primary)

Browse Files

Cancel of
Name of Insurance Company
Member ID
Insurance Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Contact Number

Area Code Phone Number
Insured's Name

First Name Last Name
Insured's Date of Birth (if different than patient)

Month Day Year
Date
Insured’s Employer Name:
Insured's relationship to patient
I have a secondary insurance
Claim #
Insured's SS#
Front of Insurance Card (Secondary)

Browse Files

Cancel of
Back of Insurance Card (Secondary)

Browse Files

Cancel of
Name of Secondary Insurance Company
Member ID
Insurance Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Contact Number

Area Code Phone Number
Insured's Name

First Name Last Name
Insured's Date of Birth *

Month Day Year
Date
Insured’s Employer Name:
Insured's relationship to patient
Injury/Medical Information
Referring Physician

First Name Last Name
Primary Care Physician Name

First Name Last Name
Reason for your visit
Date of Injury

Month Day Year
Date
Did you have surgery for this injury?
Date of Surgery

Month Day Year
Date

Rate your pain at its worst on a scale of 1 (low) to 10 (high)

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

Rate your pain at its best on a scale of 1 (low) to 10 (high)

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

How often do you experience the pain/symptoms?
Since your symptoms began, have you noticed any of the following

Fatigue Pain at night Leg swelling Weight loss/gain Numbness or tingling Abdominal pain Fainting Skin changes Heart palpitations
Are your symptoms related to a work injury?

Yes No
Or a motor vehicle accident?

Yes No
List past surgeries or major medical problems/illness
List of Medication
History

Yes

Alzheimer's

Cardiovascular Disease

Cerebral Vascular Accident

Diabetes

Fibromyalgia

High Blood Pressure

Cancer

Immunocompromised

Osteoarthritis

Rheumatoid Arthritis

Parkinson's

Traumatic Brain Injury

Other

Please list "other" conditions:
Are you currently under the care of any healthcare provider other than who prescribed your Physical Therapy?

Yes No
If yes, what is the reason?
Authorization/Consent
- PATIENT INFORMATION CONSENT POLICY
  I authorize PT Revolution (PTR) to use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I also understand that PTR will consider requests for restriction on a case-by-case basis, but does not have to agree to requests for restrictions. I understand that my personal health information is subject to disclosure by the facility receiving it for legal purposes.
- TREATMENT CONSENT POLICY
  I authorize PTR to provide any and all treatment which they, in their professional judgment, feel will help me improve. I understand that they cannot guarantee success and that some forms of treatment are painful. I understand therapy requires my participation and my adherence to my home program is necessary for success.
- FINANCIAL POLICIES
  I authorize my insurance benefits to be charged (if applicable) directly the facility and that I am responsible for any cost in any case my insurance claim be denied.
- Insurance is a contract between you and your insurance company. We are NOT a party to that contract in most cases. We file insurance claims as a courtesy to our patients. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, “allowable” charges, etc., other than to supply factual information as necessary.
- PT Revolution (PTR) partners with Mind Body Physical Therapy (MBPT) as the fiscal agent for billing physical therapy services. Thus, I authorize my insurance company to pay MBPT directly for my care. I understand that I am responsible for all charges not covered by my insurance. Deductibles and co-payment amounts are required at the time of service, unless other arrangements have been authorized by the office manager. If payment is not received from the insurance company within 45 days, it becomes the patient’s responsibility and there will be a 1.5% per month interest charge on all remaining balances. You are responsible for timely payments of your account. Should this account become delinquent, you will be responsible for all reasonable costs of collection.
- WORKER’S COMPENSATION
  We will bill your employer’s industrial insurance. If your injury is determined to NOT be work related, you will be responsible for the balance due in 30 days, or we reserve the right to bill any private insurance you have.
- LIENS
  Upon verification by your attorney, we will accept your lien. The patient understands that we will be paid the full balance of our bill once the case settles.
- SCHEDULING POLICY
  Please schedule each appointment with us in advance to obtain optimum times; we will not automatically do this. Please be advised that we require 24 business hours notice to cancel an appointment and we are not open weekends, so a Monday cancellation must be provided by the preceding Friday. If you are unable or feel you should not attend an appointment, please discuss your options with us.
  You, not your insurance provider, are responsible for any cancellation/no show charges and will be billed directly as follows:
  No Call / No Show: $50, cancelling without 24 business hours notice: $25.
Name & signature of patient/legally responsible person *

Clear
Release of Confidential Information Authorization

If the person or entity receiving the following information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed to the individuals or institutions and no longer protected by these regulations. You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment or payment or your eligibility for benefits. You may inspect or copy the protected health information to be used or disclosed under this authorization. Finally, you may revoke this authorization in writing at any time by sending written notification to PT Revolution at 2038 Lake Tahoe Blvd, South Lake Tahoe, CA 96150. Your notice will not apply to actions taken by the requesting person/entity prior to the date they receive your written request to revoke authorization.
I hereby allow PT Revolution to release relevant information pertaining to and regarding the provision of physical therapy services.
Name & signature of patient/legally responsible person *

Clear
HIPAA Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

This notice is presented to you as required by federal law as of the effective date.

If you have any questions about this notice, please contact PT Revolution.

Who Will Follow This Notice
This notice describes our office’s practices. We may share information with each other for your care.

Our Pledge Regarding Medical Information
We understand that medical information about you and your health is personal. We are committed to protecting your medical information. We create a record of the care you receive at this office to provide you with quality care and to comply with legal requirements. This notice will tell you about the ways in which we use and disclose your medical information. We also describe your rights and the obligations we have regarding the use and disclosure of medical information. We are required by law to make sure that medical information that identifies you is kept private; give you this notice of our privacy practices with respect to your medical information; and follow the terms of the current notice.

How We May Use and Disclose Medical Information About You:

For Treatment
We may use information about you to provide you with medical treatment. We may disclose medical information about you to office staff and others involved in your care.

For Payment
We may use and disclose information about you for insurance and payment services.

For Health Care Operations
We may use and disclose information about you for practice operations to make sure that you receive quality care and for learning purposes.

Appointment Reminders
We may use and disclose information to contact you about appointments.

Phone/Text Messages
We may call or text and leave messages on your device or with whoever answers the phone at your house or on your voicemail unless directed otherwise.

Treatment Alternatives
We may use and disclose information to tell you about treatment options.

Health-Related Benefits and Services
We may tell you about health-related benefits or services.

Individuals Involved in Your Care or Payment for Your Care
We may release medical information about you to a friend or family member who is involved in or helps pay for your medical care. We may disclose medical information about you to assist in a disaster relief effort.

As Required By Law
We will disclose information about you when required to do so by law.

To Avert a Serious Threat to Health or Safety
We may use and disclose information about you to prevent a serious threat to your health and safety, the public or to another person.

Special Situations:
Organ and Tissue Donation
If you are an organ donor, we may release information to organ banks.

Military and Veterans
We may release information about military personnel as required.

Workers’ Compensation
We may release information about you for workers’ compensation.

Public Health Risks
We may disclose information about you for public health activities.

Health Oversight Activities
We may disclose information to a health oversight agency.

Lawsuits and Disputes
We may disclose information about you in response to a court or administrative order, a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request.

Law Enforcement
We may release information to a law enforcement official as required by law.

Coroners, Medical Examiners and Funeral Directors
We may release information to a coroner, medical examiner or funeral director as necessary.

National Security and Intelligence Activities and Protective Services for the President
We may release information about you to authorized federal officials for national security activities.

Inmates
We may release information about inmates to a correctional institution or law enforcement.

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy
You have the right to inspect and copy your medical information. This includes medical and billing records, but does not include psychotherapy notes. You must submit your request in writing to PT Revolution at the address above. We may charge a fee for the costs of copying. We may deny your request to inspect and copy. You may request that the denial be reviewed. Another neutral health care professional, not the person who denied your request, will review your request and the denial. We will comply with the outcome of the review.

Right to Amend
If you feel that your information is incorrect or incomplete, you may ask us to amend the information. You may request an amendment as long as the office has this information. Your request must include the reason, be made in writing and submitted to PT Revolution. We may deny your request if you ask us to amend information not created by us, unless the person that created the information is no longer available; is not part of the information kept by the practice; is not information which you would be permitted to inspect and copy; or is accurate and complete.

Right to an Accounting of Disclosures
You have the right to request a list of the accounting of disclosures we made of your medical information. You must submit your request in writing to PT Revolution. Your request must state a time period, not longer than six years, and indicate whether you want the list on paper or electronic. Your first requested list within a year is free.

Right to Request Restrictions
You have the right to request a restriction or limitation on the information we use or disclose about you for treatment, payment, and health care operations or to someone who is involved in your care or the payment for your care. We are not required to agree to your request. If we agree, we will comply with your request unless the information is needed in an emergency. You must make your request in writing to PT Revolution. You must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.

Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain way or location. You must make your request in writing to PT Revolution. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. We have the right to deny your request.

Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, request verbally or in writing to any PT Revolution staff.

Changes to this Notice
We reserve the right to change this notice and make the revised notice effective for information we already have about you as well as any future information. We will post a copy of the current notice in the office. Each time you register at the office we will offer you a copy of the current
notice.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with our office or
with the Secretary of the Department of Health and Human Services. To file a complaint with the
office, contact PT Revolution at 2038 Lake Tahoe Blvd, South Lake Tahoe, CA 96150 or email to admin@ptrevolution.com. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses of Medical Information
Other uses and disclosures of information not covered by this notice will be made only with your written permission. You may revoke that permission in writing at any time. Understand that we are unable to take back any permitted disclosures, and that we are required to retain records of your care.
Signature *

Clear
Date

Month Day Year
Date
Reason why patient is unable to sign (if applicable)
COVID Compliance

PT Revolution takes your safety, the safety of our staff, and the safety of anyone in our facility extremely seriously. We believe Physical Therapy should occur in person and therefore require adherence to the following guidelines. Thank you in advance for your cooperation in minimizing the risk of COVID-19 transmission.
In order to protect the health and welfare of those around you and in the PT Revolution facility, we require you:

1) Maintain a distance of six (6) feet from other persons whenever possible.
2) Wear a face mask, and to not remove the mask except when directed by staff.
3) Temp check and sanitize ands upon arrival for all appointments.
4) Practice proper cough & sneeze etiquette by coughing/sneezing into your elbow, and to give warning to others if you are about to cough or sneeze, so that others can maintain a safe distance.
5) Immediately notify PT Revolution staff if you develop symptoms of COVID-19 or test positive for COVID-19 within fourteen (14) days of your last visit.
Should be Empty:

Physical Therapy Patient Intake Form

Personal Information

Emergency Contact

Payment Information

Injury/Medical Information

History

Authorization/Consent

Release of Confidential Information Authorization

HIPAA Notice of Privacy Practices

COVID Compliance