Essential Rehab Care

Medical History
Personal Information
Name *

First Name Last Name
Today's Date

Month Day Year
Date
Date of Birth *

Month Day Year
Date
Soc. Sec #
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone *
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Marital Status:

Single Married Partnered Divorced Widowed Separated
Sex:

Male Female
Referring Physician
Phone Number
Please enter a valid phone number.
How did you hear about our practice?

Emergency Contact
Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Relation

Primary Insurance

If you have accident, no-fault or compensation, please put your insurance information on the next page
Insurance Company *
Insurance ID # *
Group # *
Please enter the policyholder's information below, if you are the policyholder yourself. Are you policyholder yourself? *

Yes No
Policyholder's Name *

First Name Last Name
Relationship to patient *
Soc. Sec. #
Birthdate *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone *
Please enter a valid phone number.
Work Phone *
Please enter a valid phone number.
Front Side Insurance

Cancel of
Back Side Insurance

Cancel of
Do You Have Secondary Insurance?

Yes No

Secondary Insurance

This section is only for patients who have Medicare as primary insurance. See billing and collection policies for info
Insurance Company *
Insurance ID # *
Insurance Group # *
Please enter the policyholder's information below, if you are the policyholder yourself. Are you policyholder yourself? *

Yes No
Policyholder's Name *

First Name Last Name
Relationship to patient *
Soc. Sec. #
Birthdate *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone *
Please enter a valid phone number.
Work Phone *
Please enter a valid phone number.

Assignment and Rules
I hereby authorize payment directly to Essential Rehab Care LLC of all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for ill charges, whether or not paid by insurance, and for all services rendered for me or for my dependents. I authorize the providers, staff, and billing agents for this practice to release any information required to secure the payment of benefits. I authorize the use of my signature on all insurance submissions. I authorize a copy of this document to be used in place of the original. I have read and agreed to the above.
Date *

Month Day Year
Date
Signature of Patient or Guardian: *

Clear

Privacy Practices Acknowledgement and Consent Form
- I have received your Notice and Privacy Practices and or I have been provided an opportunity to review it.
- I agree that telephone messages regarding my appointments, prescription renewals, lab results, and all other Protected Health Information ("PHI"), may be left for me on voicemail systems and answering machines at the following telephone numbers, in addition to any other numbers provided to you by me:
Phone Number
Please enter a valid phone number.
Home/Office/Cell Other
Phone Number
Please enter a valid phone number.
Home/Office/Cell Other
Phone Number
Please enter a valid phone number.
Home/Office/Cell Other
Please Check the Boxes Below

I agree that my PHI may be shared with my spouse(if applicable). I agree that my PHI may be shared with my other medical providers. I agree that my PHI may be shared with the following other people.
Please Check the Boxes Below

I understand that I can change any of the foregoing agreements, at any time, by giving written notice to Essential Rehab care to the attention of the HIPPA Compliance Officer. I agree that Essential Rehab may contact me at any email addresses provided to you by me regarding both PHI and non-PHI. As defined in the Health Insurance Portability and Accountability Act of 1996 and its regulations, as may be amended from time to time ("HIPAA"
Patient Name: *

First Name Last Name
Signature of Patient and Guardian: *

Clear
Date: *

Month Day Year
Date

New Patient Acknowledgements
Patient Name: *

First Name Last Name
Consent to Treatment:

I consent to and authorize Essential Rehab care to administrator rehabilitation therapy treatment. I understand and am informed that, as in the practice of medicine, rehabilitation therapy may have some risks. I understand that I have the right to ask about these risks and have any questions about my conditions answered prior to treatment. I know it ¡s up to me to inform my provider of rehabilitation therapy about any health problems or allergies I have as well as medications I am taking. I understand that the practice of rehabilitation therapy is not an exact discipline and I acknowledge that no guarantees have been made to me regarding treatment and/or treatment results from the rehabilitation therapy.

Authorization to Release/Obtain Information:

I hereby authorize the release of my patient health care information for the purpose of treatment of payment, to my physician, insurance company, adjustor, attorney, or other health care organizations pertinent to my case. Further, I authorize Essential Rehab and any other health care organization pertinent to my case. This correspondence can be made via mailings, telephone, and/or facsimile.

Insurance Eligibility:

Verifications of benefits are NOT a guarantee of payment. Payment is determined by your insurance company at the time a claim is received. We provide you with the information as it is outlined by your insurance company. It is your responsibility to fully understand your insurance benefits.

Financial Responsibility:

Payment is due at the time of treatment. I agree to pay Essential Rehab all amounts that are due for services rendered which is not otherwise paid for by my insurance plan on my behalf. In the event that my account is referred to a collection agency or an attorney. I further agree to pay all the reasonable costs incurred to collect any amounts that are due for services rendered including, without limitation, reasonable attorney's fees.

Assignment and Release of Benefits:

I hereby appoint Essential Rehab as my authorized representative, and assign to it my right, to file for, receive and recover any and all monies payable for the care which it rendered to me from any third party claims payment source, including my health insurer, Medicare, Medicaid or other governmental program (collectively, my "Plan"), while I was eligible to receive such claim payment. I authorize you to send and receive documentation related to my treatment to and consent to your discussing my treatment with, my Plan. I also authorize Essential Rehab to take any and actions necessary to assert and pursue my legal rights to receive such claim payment under the terms of my Plan through any appeals and/or grievances and/or litigation and/or arbitration available to me for such purpose. As the assignor of the foregoing payment amounts. I direct that such payment be sent by my Plan to Essential Rehab and, in the case that payment is made by my Plan to me. I agree to remit such payment in full to Essential Rehab not later than ten (10) days after my receipt.
Patient Signature: (Guardian signature if patient is under 18 years) *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date

Billing and Collection Policies
Upon Scheduling and Registration:

We require you to provide your medical insurance card, plot identification your address Date of Birth, and phone number. If you receive health benefits through a spouse, partner or rent, we require you to provide that person's information as well for Collection purposes, we require social security numbers. Intentionally failing to notify us of changes to your insurance coverage may be a fraud.

Keeping Appointments:

Patients must call one full business day in advance by the same time as my appointment one business day in advance cancel an appointment Failure to attend an appointment of cancellation on less than one full business days' notice quant may be charged 55 per No Show. (This fee does not apply to Medicare beneficiaries.) Failure to pay such charges in full may constitute of contract and of the provider-patient relationship, leading to your dismissal from the practice. By signing below, you accept and agree to make policies.

Participating Insurance Plans:

We are participating with most insurance plans. It is your responsibility to understand the provisions of your health insurance plan and coverage. We recommend contacting your carrier prior to receiving services in order to verify your coverage levels and responsibilities, and to all written terms and limitations of your plans prior to seeking service. You are wholly responsible for your coverage limitation, regardless of whether you are aware of the details. If you have both commercial insurance and no-fault insurance, you are responsible for providing the correct insurance at your visit. If your plan requires referrals, pre-certifications, or other required documentation prior to your appointments, you are responsible for ensuring they are obtained before receiving services. If your plan requires authorization, and you do not provide such referral, authorization, or certification, you will be responsible for all charges that are not paid by your insurance carrier due to lack of authorization. By signing below you specifically agree to this and exempt yourself from any protections your insurance plan may offer you regarding this provision. By signing below, you accept and agree to these policies.

Out-Of-Network Insurance Plans:

If you have an insurance plan that we do not participate with, but through which you have out-of-network benefits, we may agree to file claims for services rendered, and wait for insurance Cartier adjudication before billing you for the balance of the charges. Patients utilizing out-of-network benefits are responsible for paying an amount at check-in equivalent to their copayment amount (or $25 if there is no copay amount printed on the card) as patient payment toward their financial responsibility. If your plan advises us that you do not have coverage for the services rendered out-of-network, you will be billed for the entire balance. If your plan issues payment for services rendered out-of-network, you may be responsible for some or all of the remaining balance, which we will invoice you for Balance bills are due immediately upon receipt, by endorsing the check over to Essential Rehab, along with a complete copy of the Explanation of benefits. (You may be responsible for payment of some or all of the balance.) Please be advised that you are paid by the insurer and you do not turn the payment over to us in full within 30 days, you will be assessed a 1.5% monthly interest rate, and your account may be turned over to collections (plus a 30% collection fee) and/or we may undertake legal proceedings against you. By signing below, you accept and agree to these policies.

Billing and Collection Policies
Custom-Fabricated Splints:

Custom splints are generally covered by Medicare, No-Faull Accident. PIP and Workers Compensation. We will submit claims for custom splints for patients with commercial insurance as a courtesy, but require payment up-front from the patient. Should the carrier issue any payment to us for the splint, the patient will be reimbursed the lesser amount. Pricing is available upon request.

Platelet Balances and Payment:

It is our right and responsibility to bill you for any portion of your treatment that your health insurance carrier assigns to your responsibility, including deductible and coinsurance. It is your responsibility, detailed by the terms of your health insurance coverage, to pay any such portion. If you do not remit payment on any such bills within a reasonable period and with reasonable notice, action against you may be pursued. If you bounce a check, you will be responsible for a 35 fee, and will not be able to pay by personal check again. You may be dismissed as a patient by our practice for failure to meet your financial obligations.

Health Insurance non-payment:

Services that have not been paid by your health insurance carrier within 60 days of claim submission, whether or not your plan is one with which we participate, wholly become your responsibility to pay in full. If your carrier later pays us for those services, you will be reimbursed for the difference. By signing below, you accept this policy.

Self-pay Patients:

If you do not have health insurance, it is our policy that you must pay for your service before leaving the office. We offer a discount for payment at the time of service which is only available on accounts that are paid in full at the time of service. A hardship discount is available for qualifying individuals upon request prior to the rendering of services.

I have read, fully understand, accept and agree to comply with all the above policies.
Patient Name *

First Name Last Name
Signature of Patient or Guardian: *

Clear
Date: *

Month Day Year
Date

Medical History

Personal Information

Emergency Contact

Primary Insurance

Secondary Insurance

Assignment and Rules

Patient Medical Questionnaire

Privacy Practices Acknowledgement and Consent Form

New Patient Acknowledgements

Billing and Collection Policies

Billing and Collection Policies

Quick DASH Questionnaire

Covid-19 Questionnaire