Patient Intake Form

General Patient Intake Form

Please fill out all required fields:
Treatment Location
Which Office Are You Currently Being Treated At*

AmityvilleArdsleyBabylonBayshoreBellmoreBethpageBuchananCenter MorichesCarroll Gardens,BrooklynCommackCrotonEast NorthportFranklin SquareGarden CityGlen CoveGreat NeckGreenvaleGrotonHampton BaysHarrisonHauppaugeHewlettHoltsvilleHuntington StationJerichoLake RonkonkomaLong BeachMineolaMohegan LakeMystic, CTNew Hyde ParkOakdaleOceansideOyster BayPatchoguePlainviewPort Jefferson StationPort WashingtonRidgeRiverheadRockville CentreRocky PointSayvilleSeldenSetauket on Main StreetSetauket on Technology DriveSmithtownSt. JamesWading RiverWest BabylonWest WarwickWesterly- 55 Beach StreetWesterly- 85 Beach Street
Please Choose Treatment Location:*
Personal Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age?
Sex?*

MaleFemale
Sex?*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Is this your home, work, or cell phone?
Phone Number

Area CodePhone Number
Is this your home, work, or cell phone?
Emergency Contact
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship*
May we send you text messages for your appointment reminders to the numbers listed above?*

YesNo
Preferred Contact for Appointment Reminders*

CallText
May we send you text messages for marketing materials, including patient review request, to the number(s) listed above? By marking yes, you understand that text messages may not be secure, with a risk of unauthorized access to your information.*

YesNo
May we send you emails relating to your care with us? By providing your email address, you understand that the emails may not be secure, with a risk of unauthorized access to your information*

YesNo
Do you give us authorization to leave you a voicemail regarding (Please check all that apply):*

Your TreatmentYour Insurance Benefits
You may revoke this Consent at any time in writing. Your revocation will be acted upon and implemented upon receipt of your written revocation except to the extent the Clinic has relied upon this Consent.
You may revoke this Consent at any time in writing. Your revocation will be acted upon and implemented upon receipt of your written revocation except to the extent the Clinic has relied upon this Consent.
Patients will receive phone calls, text messages and/or emails for appointment reminders and patient satisfaction surveys for quality assurance purposes.*

I Acknowledge
E-mail (For office use only regarding hours, closings, and newsletters)*
Do you require an interpreter?

YesNo
Preferred Language?
Marital Status*
Student Status*
Current Symptoms
Primary Region of Complaint:*

BackHipKneeAnkleFootStrokeNeurologicalJawNeckShoulderElbowWrist/HandWeakness/ParalysisBalance/Coordination
Primary Region of Complaint:*
Involved Side:*

LeftRightBoth
Involved Side:*
Dominant Side (Which side of your body is stronger?):*

LeftRight
Dominant Side (Which side of your body is stronger?):*
Date of Onset (When did symptoms/pain begin?):

MonthDayYear
Briefly describe the history of your injury/ symptoms:
Symptoms:

PainSwellingLockingStiffnessGiving WayWeaknessCrampsInstabilityMuscle SpasmsClickingNumbnessFaintingTinglingHeadachesOther
Does symptoms interfere with your (Select all that apply):

WorkSleepDaily RoutineRecreationNone
How would you describe changes with your symptoms?

Getting betterNot changingGetting worse
What makes your symptoms better?

MedicationLaying downStandingSittingStrechingNothingOther
What makes your symptoms worse?

BendingLiftingTwistingHouseworkSittingStandingWalkingRunningDrivingOther
Pain - Describe your pain:

SharpRadiatingStabbingDull AcheBurningPins & Needles

Pain intensity at rest:*

	0	1	2	3	4	5	6	7	8	9	10

0 is None, 10 is Severe

Pain intensity during activities:*

	0	1	2	3	4	5	6	7	8	9	10

0 is None, 10 is Severe

Who have you seen about your symptoms?*

Medical DoctorChiropractorAcupunctureOccupational TherapistPhysical TherapistLymphedema TherapistSpeech TherapistMassage Therapist
Who have you seen about your symptoms?
What was the diagnosis and treatment given?*
Have you had a diagnostic test?*

YesNo
Type of test, results and date?*
Have you had surgery for your condition?*

YesNo
Type of surgery & date?*
What goals do you want to achieve in PT, OT, and/or SLP?*
Medical History Information
Medical History: Select all that apply*

NoneArthritis: RA / OAAsthmaBalance ProblemsCancerDepressionDiabetesDizzinessEpilepsy/SeizuresEasy BruisingGeneral FatigueHeart DiseaseHerniaHerniated DiskHistory of fallsHigh blood pressureLow blood pressureMuscle CrampsOsteoporosisPacemakerParkinson diseasePinch NervePulmonary DiseaseScoliosisWeight GainWeight LossSensitivity to heatSensitivity to coldShortness of breathSkin sensitivitySpinal Disc DiseaseStroke/CVASwollen LegsSwollen FeetThirsty OftenThyroid ProblemsTightness in chestVision ProblemsUse of Blood ThinnersAnemiaAnxiety/Panic DisorderMetal ImplantsBowel or Bladder ProblemsHearing ImpairmentOther
Please list any allergies you have:*
Are you currently or could you be pregnant?

YesNo
Are you currently or could you be pregnant?
Have you had other surgeries in the last 5 years?*

YesNo
Have you had other surgeries in the last 5 years?
Reason for Surgeries and Dates:
Weight*
Have you fallen more than once in the past year?*

YesNo
Have you fallen more than once in the past year?
If yes, how many times?
If yes, were you in
If yes, were you injured?

YesNo
Do you feel unsteady when standing or walking?

YesNo
Do you feel unsteady when standing or walking?
Do you worry about falling?

YesNo
Do you worry about falling?
List of Current Medication(s)*
Social History
Are you currently working?

YesNoRetired
Are you currently working?
If No, do you have a job that you are trying to return to?

YesNo
Occupation?
Exercise?

YesNo
Exercise
Hours per week?
Intesity

LightModerateStrenuous
Intensity
Alcohol?

YesNo
Drinks per week:
Smoke?

YesNo
Smoke?
Cigarettes per day
Smoked in the past?

YesNo
Smoked in the past?
How Long?
Caffeine

YesNo
Caffeinated Beverages per day
Recreational Drugs

YesNo
How much?
Home Environment
Do you live alone?*

YesNo
Do you live alone?*
If No, who do you live with?
Do you use an assistive device?*

YesNo
Do you use an assistive device?
If Yes, what type of device and for how long?
Do you have stairs outside your home?*

YesNo
Do you have stairs outside your home?
How many steps?
Handrails?

YesNo
Handrails?
Which side are the rails on?

LeftRight
Which side are the rails on?
Do you have steps Inside your home?*

YesNo
Do you have steps Inside your home?
How many steps?
Handrails?

YesNo
Handrails?
Which side are the rails on?

LeftRight
Which side are the rails on?
PHQ-2
Over the last 2 weeks, how often have you been bothered by the following problems?
1. Little interest or pleasure in doing things*
2. Feeling down, depressed, or hopeless*
Within the last 12 months:
Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?*

YesNo
Has anyone prevented you from getting food, clothes, medication, glasses, hearing aides or medical care, or from being with people you wanted to be with?*

YesNo
Have you been upset because someone talked to you in a way that made you feel shamed or threatened?*

YesNo
Has anyone tried to force you to sign papers or to use your money against your will?*

YesNo
Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?*

YesNo
WellRX

Complete if you are 18+
1) In the past 12 months, did you worry that your food would run out beforeyou got money to buy more or did the food you bought run out before you hadmoney to buy more?*

YesNo
2) Are you worried that in the next two months you may not have stable housing or become homeless?*

YesNo
3) Do you have trouble paying for your gas or electricity bills?*

YesNo
4)Do you put off going to doctor appointments or have trouble finding or paying for a ride (transportation)?*

YesNo
5) Do problems with daycare make it difficult for you to work or study?*

YesNo
6) Are you without regular income or have difficulty paying your bills?*

YesNo
7) Do you need help finding a better job?*

YesNo
7) Do you have a high school degree?*

YesNo
9) Are you concerned about someone in your home using drugs or alcohol?*

YesNo
8) Do you feel unsafe in your daily life?*

YesNo
Select all that Apply

Feel unsafe at homePhysically or emotionally hurtInjuriesPhysically or emotionally threatenedNeglectMade to feel afraidPrefer not to sayOther
11) Do you need help with legal issues?*

YesNo
In the last 6 months have you been at the Emergency Department more than twice?*

YesNo
In the last 6 months, have you been hospitalized?*

YesNo
Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?*

YesNo
Referral Information
For our records, list the names and numbers of your doctors:
Referring MD:
Specialty:
Phone #:
Primary MD:
Phone #:
How did you hear about Metro Physical & Aquatic Therapy?*

PhysicianHospital Network (HSS/ NYU Network)Silver Sneakers ClassMeadowbrook PointeInternet Search (Google, Yelp, ZocDoc)Insurance CompanyCommunity Center (YMCA/JCC, etc)Drove by the officeEventEmployerCase ManagerFormer PatientAdjusterSchoolWord of MouthAttorneySelfMarketing- Ad (Print)Marketing- Ad (Direct Mail/Email)Marketing- Ad (Social Media)Other
How did you hear about Metro Physical & Aquatic Therapy?
Doctor Name?
Advertisement Name?
Family Friend Name?
Event Name?
Document/Image Submission
Use this section to upload files of your photo ID, insurance card, imaging reports, prescriptions, medication lists, or other documents that pertain to your medical case

Browse Files

Cancelof
Insurance Provider/Policies
Who is Your Insurance Provider?*

MedicareNo FaultWorkers CompensationAny Other Major Medical Insurances
NOTICE OF PRIVACY

This is to acknowledge receipt of Notice of Privacy Practices for Metro Physical & Aquatic Therapy, Sherrie Glasser PT, P.C., Metro Physical, Occupational and Speech Therapy PLLC, Metro Physical & Occupational Therapy, Inc., and/or Metro Acupuncture, Massage, & Physical Therapy, PLLC to use and disclose my health information when necessary in connection with my treatment or care.

PATIENT BILL OF RIGHTS

∗ The right to efficient & equal service regardless of race, sex, physical or mental handicap,
religion, ethnic background, education, social class or economic status.
∗ The right of considerate, courteous & respectful care from all our staff.
∗ The right of complete information in terms the average patient can reasonably be expected to
understand.
∗ The right to informed consent and full discussion of risks and benefits prior to any invasive
procedure, except in an emergency. The right to discuss alternatives to proposed procedures.
∗ The right to obtain assistance in language interpretation.
∗ The right to know the names, titles, and professions of the staff to whom you speak and from
whom you receive services or information.
∗ The right to refuse examination, discussion and procedures to the extent permitted by law,
and to be informed of the health and legal consequences of this refusal.
∗ The right of access to your personal health records.
∗ The right of respect for your privacy.
∗ The right of confidentiality of your personal health records as provided by law.
∗ The right to expect reasonable continuity of care within the scope of services and staffing of
the facility.
∗ The right to respect for your rights and religious options.
∗ The right to present complaints to the Director of our facility without fear of reprisal.

I acknowledge receipt of Notice of Privacy Practices. I acknowledge receipt of Statement of Patient Rights.
I Acknowledge
Initials
Date of Initials

MonthDayYear
Date
Disclosure of Medical Records

I authorize Metro Physical & Aquatic Therapy, Sherrie Glasser PT, P.C., Metro Physical, Occupational and Speech Therapy PLLC, PLLC, Metro Physical & Acupuncture, Massage, & Physical Therapy, PLLC to discuss/have access to my medical and billing records for the individuals listed below.
Name of Individual*

First NameLast Name
Relationship:*
Name of Individual*

First NameLast Name
Relationship:*
FINANCIAL POLICY
I understand fully that, in the event my insurance company or financially responsible party does not pay for the services I receive, I will be financially responsible for payment.
- To assist in establishing your account, please:
  Supply all necessary information for accurate billing of your claim, including your insurance card, driver's license, employer information, and demographic information.
- Satisfy all insurance copayments, coinsurance,
  deductibles, and non-covered services, on the day services are rendered.
- Provide your insurance company with any additional information requested to complete the processing of claims filed on your behalf.
AUTHORIZATION OF PAYMENT
I hereby assign benefits directly to Metro Physical and Aquatic Therapy.
I also authorize release of any medical records to other healthcare providers as necessary to facilitate my treatment and to other third parties as necessary to process medical claims and otherwise permitted
or required in the Notice of Privacy Practices.

CANCELLATION/NO SHOW FEE POLICY

Your appointment time is valuable and has been reserved especially for you. If it is necessary to reschedule your appointment, please provide us 24 hour notice to ensure that you are not charged for the appointment. There will be a $60 fee for not showing for a scheduled appointment or not cancelling your appointment 24 hours prior to your scheduled appointment time.

TREATMENT OF MINORS

I, as a parent/guardian of a minor receiving treatment hereunder, do hereby agree and understand that I have been advised to remain on the premises
during any such treatment, and waive any
claim I may have resulting from failure to do so.
By signing below, you are acknowledging our financial policy, authorization of payment, cancellation/no show fee and treatment of minors. Please sign using finger or mouse):*

Clear
Date of Signature

MonthDayYear
Date
RTM

I hereby consent to Remote Therapeutic Monitoring (RTM) with Limber Health and Metro Physical Therapy.

I acknowledge and agree to the following terms:

Once per month copay: I understand that a monthly copay may apply for Remote Therapeutic Monitoring services. RTM services
will be billed to Medicare on the last Sunday of each month.

Limber Health Program: Through the Limber Health program, I will receive virtual support from a Care Navigator, a remote
clinician dedicated to assisting me in engaging with my home exercise program.
Signature (please sign using finger or mouse):*

Clear
Date of Signature

MonthDayYear
Date
MEDICARE PATIENT RESPONSIBILITIES

Medicare requires that your physician sign a plan of care that is established on the first date of service and periodically thereafter based upon your therapist's specific written plan. A current plan of care MUST be signed by your physician in order for us to bill Medicare. If the doctor is unwilling to sign the plan of care document, Medicare will not consider those services medically necessary and we will be unable to bill for these services. Once the plan of care is signed by your physician, we will bill your insurance carrier at our contracted rates.

Occupational/Physical/Speech Therapy services are NOT covered if you are enrolled in Home Health Care. Until you notify Medicare of your discharge date from Home Health Care, you will NOT be eligible for out-patient services. If this happens, you are responsible for the cost of the services provided. Please let us know as soon as possible if you must begin a Home Health Care program. ** Please note that home companion agencies or privately paid home care agencies are allowed**
Medicare Secondary Payor Questionnaire
Are you receiving Black Lung Benefits?*

YesNo
Are your services to be paid for by a Government Research Program?*

YesNo
Are you entitled to benefits through the Department of Veteran Affairs?*

YesNo
Is your therapy related to a non-work accident?*

YesNo
Is your therapy related to a work-related accident or condition?*

YesNo
Is your therapy related to an injury or illness covered under an automobile or premise (Home or Business) insurance*

YesNo
If yes, please provide Insurance Name
If yes, please provide Claim Number
Do you believe that another party is responsible for your injury/illness?*

YesNo
If yes, please provide Insurance Name
If yes, please provide Claim Number
Do you have a group health plan insurance based on your own current employment or the employment of either your spouse or other family member?*

YesNo
If YES, how many employees, including yourself or spouse work for the employer from whom you have Group Health Insurance?

1-1920-99100 or more
Are you under 65 and on Medicare due to DISABILITY and covered by Group Health Insurance*

YesNo
Are you under 65 and on Medicare for an End State Renal Disease (ESRD) Diagnosis*

YesNo
If YES, what was the date of your diagnosis?

MonthDayYear
Date
Have you Received maintenance dialysis treatments

YesNo
If YES, what date did your dialysis begin?

MonthDayYear
Date
Have you received a Kidney Transplant?

YesNo
If YES, what date did your dialysis begin?

MonthDayYear
Date
Signature

Clear
Date of Signature

MonthDayYear
Date
Home Care Checklist
Have you received Home Health Care services this year?*

YesNo
If Yes, Are you discharged?*

YesNo
If Yes, what Date?*
Is a skilled nurse or home health aide coming to your home?*

YesNo
Are you receiving wound care at your home?*

YesNo
Are you receiving physical/occupational/speech therapy at your home?*

YesNo
Is a social worker coming to your home?*

YesNo
Initials (please sign using finger or mouse):*

Clear
It is the patient’s responsibility to keep the front desk staff up to date with any changes to their referring MD or insurance information. This for billing purposes and should the doctor not sign off on your certification due to change in MD or infrequency of regular visits, or insurance information is not updated, you, the patient, wil be responsible for any visits not covered by a certification.
Initials (please sign using finger or mouse):*

Clear
Is your injury a result of a motor vehicle accident or work related injury?*

YesNo
If yes, you must notify the front desk if your reason for treatment is due to an auto accident or hurt on the job. Your health insurance will NOT cover your treatment and deny payment for services. You will be responsible for all outstanding balances.
Initials (please sign using finger or mouse):*

Clear
ALL OTHER MAJOR INSURANCES PATIENT RESPONSIBILITIES
Are you being treated as a Direct Access patient?*

YesNo
MEDICARE PATIENT RESPONSIBILITIES

Medicare requires that your physician sign a plan of care that is established on the first date of service and periodically thereafter based upon your therapist's specific written plan. A current plan of care MUST be signed by your physician in order for us to bill Medicare. If the doctor is unwilling to sign the plan of care document, Medicare will not consider those services medically necessary and we will be unable to bill for these services. Once the plan of care is signed by your physician, we will bill your insurance carrier at our contracted rates.

Occupational/Physical/Speech Therapy services are NOT covered if you are enrolled in Home Health Care. Until you notify Medicare of your discharge date from Home Health Care, you will NOT be eligible for out-patient services. If this happens, you are responsible for the cost of the services provided. Please let us know as soon as possible if you must begin a Home Health Care program. ** Please note that home companion agencies or privately paid home care agencies are allowed**
MEDICARE PATIENT RESPONSIBILITIES

Medicare requires that your physician sign a plan of care that is established on the first date of service and periodically thereafter based upon your therapist's specific written plan. A current plan of care MUST be signed by your physician in order for us to bill Medicare. If the doctor is unwilling to sign the plan of care document, Medicare will not consider those services medically necessary and we will be unable to bill for these services. Once the plan of care is signed by your physician, we will bill your insurance carrier at our contracted rates.

Occupational/Physical/Speech Therapy services are NOT covered if you are enrolled in Home Health Care. Until you notify Medicare of your discharge date from Home Health Care, you will NOT be eligible for out-patient services. If this happens, you are responsible for the cost of the services provided. Please let us know as soon as possible if you must begin a Home Health Care program. ** Please note that home companion agencies or privately paid home care agencies are allowed**
Initials (please sign using finger or mouse):*

Clear
It is the patient’s responsibility to keep the front desk staff up to date with any changes to their referring MD or insurance information. This for billing purposes and should the doctor not sign off on your certification due to change in MD or infrequency of regular visits, or insurance information is not updated, you, the patient, wil be responsible for any visits not covered by a certification.
Initials (please sign using finger or mouse):*

Clear
Is your injury a result of a motor vehicle accident or work related injury?*

YesNo
If yes, you must notify the front desk if your reason for treatment is due to an auto accident or hurt on the job. Your health insurance will NOT cover your treatment and deny payment for services. You will be responsible for all outstanding balances.
Initials (please sign using finger or mouse):*

Clear
WORKERS COMPENSATION PATIENT RESPONSIBILITIES
Employment Status*
Do you have a physician’s prescription for physical therapy/occupational therapy/speech therapy and/or acupuncture treatment?*

YesNo
If yes, You DO have a prescription which is valid for the duration indicated from the date of your physician visit. If the prescription does not have a duration, it is only valid for ONE MONTH from the date of your physician visit. It is the patient’s responsibility to acquire a new prescription to continue therapy when needed.
If No, Workers Compensation DOES NOT participate in Direct Access and physical therapy/occupational therapy/speech/acupuncture MUST be prescribed by your physician to be covered. I understand that failure to comply with the above will either result in termination of any treatment or if due to Workers Comp Denial, will make me responsible for the payment of the visits. It is the patient’s responsibility to acquire a prescription.
Have you had an Independent Medical Examination (IME)?*

YesNo
Date

MonthDayYear
Date
If Yes,

I understand that services can be denied due to the results or failure to appear to a scheduled IME. I am required to inform the results and I will bring a copy of any/all IME reports for our records.
Is an Independent Medical Examination (IME) scheduled?*

YesNo
If Yes,

I understand that services can be denied due to the results or failure to appear to a scheduled IME. I am required to inform the results and I will bring a copy of any/all IME reports for our records.
If No,

I understand that I am required to inform Metro Physical and Aquatic Therapy when the carrier schedules me for any IME. Furthermore, I am required to inform Metropolitan Physical Therapy of the date and results of the IME and I will bring a copy of any/all IME reports for their records.
Initials (please sign using finger or mouse):*

Clear
Concurrent Treatment
Under Workers Compensation regulations, you CANNOT see a chiropractor, physical, massage, occupational, or speech therapist on the same day whether at MetroPT, and or elsewhere. If services are denied due to non-compliance with this regulation, you will be held responsible for denied services.
Initials (please sign using finger or mouse):*

Clear
WORKERS’ COMPENSATION AUTHORIZATIONS

Please be advised that as of 12/01/2010, the NYS Workers’ Compensation Board established Medical Treatment Guidelines for treatment rendered to the Mid/Low Back, Knee, Shoulder, Neck, and Carpal Tunnel Syndrome. According to the guidelines, the patient is allowed 12 visits of physical/occupational treatment without authorization for a recent date of injury and/or no previous physical/occupational therapy treatment under the case. The carrier will confirm the specific initial period allowed at time of verification. According to WCB Guidelines, for the body parts listed above, an MTG is required to continue physical/occupational therapy once the initial treatment period is exhausted. Any recent surgeries allow 12-18 visits without authorization. Body parts not included in the Medical Treatment Guidelines require MTG authorization.

Under the WCB Medical Treatment Guidelines, if your referring physician prescribes further physical/ occupational treatment after initial period, the referring MD is required to complete the MTG authorization forms to request authorization from the carrier for additional treatment that exceeds the initial treatment.

In order for you to continue treatment after the initial period, you must contact your physician to ask him/her to request the required MTG authorization. Your treatment will not be covered unless your physician obtains the required authorization from your workers’ compensation carrier. Please keep in mind that, according to WCB regulations, the carrier/adjuster has 15-30 days to approve or deny a MTG authorization.

As a courtesy, we will notify you in advance when authorization is required. This allows time for you to contact your physician so that he/she may request and obtain authorization on your behalf. However, in order for your physician to request further authorization he/she needs to attach a current medical report to the authorization request. It is your responsibility to see your physician every 4-6 weeks.

Should you have any questions please do not hesitate to ask for assistance. It is a pleasure to have you as our patient and we are here to assist you in any way possible.

I have read the above and agree to the terms and conditions.
Signature (please sign using finger or mouse):*

Clear
NO FAULT INSURANCE PATIENT RESPONSIBILITIES
Do you have a physician’s prescription for physical therapy/occupational therapy/speech therapy and/or acupuncture treatment?*

YesNo
If yes, You DO have a prescription which is valid for the duration indicated from the date of your physician visit. If the prescription does not have a duration, it is only valid for ONE MONTH from the date of your physician visit. It is the patient’s responsibility to acquire a new prescription to continue therapy when needed.
Date

MonthDayYear
Date
If Yes,

If your no fault case is determined to be closed, or that benefits are denied, we will bill your private insurance, if provided to us. Some private insurances require prior authorizations and do not back date authorizations from the start of your No Fault denial. I understand that I am responsible for all visits denied.
Is an Independent Medical Examination (IME) scheduled?*

YesNo
If Yes,

I understand that by law I will be responsible for all visits denied due to the results of an IME or due to failure to appear to a scheduled IME.
If No,

I understand that I am required to inform Metro Physical and Aquatic Therapy when the carrier of my No Fault case schedules me for any IME. Furthermore, I am required to inform Metropolitan Physical Therapy of the date and results of the IME and I will bring a copy of any/all IME reports for their records.
Initials (please sign using finger or mouse):*

Clear
NEW YORK MOTOR VEHICLE NO FAULT INSURANCE LAW ASSIGNMENT OF BENEFITS FORMS

(FOR ACCIDENTS OCCURRING ON AND AFTER 3/1/2002)

I, ("Assignor") herby assign to Metro Physical Therapy ("Assignee") all rights and privileges and remedies to payment for health care services provided by assignee to which I am entitled under Article 51 (the No-Fault statute) of the Insurance Law.

I, ("Assignor") herby assign to Metro Physical Therapy ("Assignee") all rights and privileges and remedies to payment for health care services provided by assignee to which I am entitled under Article 51 (the No-Fault statute) of the Insurance Law.

The Assignee herby vertifies that they have not received any payment from or on behalf of the Assignor and shall not pursure payment directly from the Assignor for services provided by said Assignee for injuries sistained due to the moto vehicle accident which occured on _______, not withstanding any other agreement to the contrary.

This agreement may be revoked by the assignee when benefits are not payable based upon the assignor's lack of coverage and/or violation of a policy condition due to the actions or conducts of the Assignor.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERICAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIN, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION DAMAGE OR CONCERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, CIMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATION CLAIM FOR EACH VIOLATION.
Print Patient Name ("Assignor")*
Print Hospital or Health Care Provider Name ("Assignee")*
Print Accident Date*
Please Sign (please sign using finger or mouse):*

Clear
Date of Signature*
Concurrent Treatment
Under No Fault regulations, you CANNOT see a chiropractor, physical, massage, occupational, or speech therapist on the same day whether at MetroPT, and or elsewhere. If services are denied due to non-compliance with this regulation, you will be held responsible for denied services.
Initials (please sign using finger or mouse):*

Clear
PHYSICAL | OCCUPATIONAL | SPEECH THERAPY CONSENT FOR TREATMENT
PROPOSED INTERVENTION/TREATMENT MAY INCLUDE ONE OR MORE OF:
Therapeutic Exercise, Gait Training, Modalities, CPM, Pool Therapy, Wound Care, Patient Education, Bed/Transfer mobility, Manual Therapy, Oral Motor Exercises, Voice Therapy, Patient & Caregiver Education.
SOME POSSIBLE RISK FACTORS/COMPLICATIONS:
Exercise: Sore muscles and joints. Transfers and Gait Training: falls, injury from falls. Manual Therapy: sore joints & ligaments, dislocation, fracture, paralysis, or death. Modalities: rash, burns, skin damage. Pool Therapy: skin irritations, drowning. Wound care: skin irritations, infection, increased wound size. Swallowing
Therapy: Aspiration & pneumonia risks.
GOAL OF TREATMENT:
Decrease Pain - Improve mobility - Improve Function - Improve Independence - Increase Quality of Life

I consent to rehabilitation and related services at Metro Physical and Aquatic Therapy. In doing so, I understand, acknowledge and affirm, that such rehabilitation and related services may involve bodily contact, touch, and/or direct contact of a sensitive nature.
Printed name of patient/legal guardian:*
Signature of patient/legal guardian (please sign using finger or mouse):*

Clear
Date Signed*

MonthDayYear
Treatment of Minors:

I, act a parent/guardian of a minor receiving treatment hereunder, do hereby agree and understand that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resulting from failure to do so.
Printed name of patient/legal guardian:*
Date Signed*

MonthDayYear
Liability:

I know and agree that Metro Physical and Aquatic Therapy is not responsible for lost or damage to personal valuables.

Waiver and Release:

I hereby release, discharge and acquit, Metro Physical and Aquatic Therapy, its agents, representatives, affiliates, employees, or assigns, of any from any/all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive, or allow, emergency and/or medical services including but not limited to ambulance services, emergency medical technicians, physician or urgent care services.
Printed name of patient/legal guardian:*
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Date Signed*

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I certify that all the information provided herein is true and correct.
Printed name of patient/legal guardian:*
Date Signed*

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Should be Empty:

General Patient Intake Form

Treatment Location

Personal Information

Emergency Contact

Current Symptoms

Medical History Information

Social History

Home Environment

PHQ-2

ELDER ABUSE SUSPICION INDEX © (EASI)

Within the last 12 months:

WellRX

Referral Information

For our records, list the names and numbers of your doctors:

Document/Image Submission

Insurance Provider/Policies

PATIENT BILL OF RIGHTS

Disclosure of Medical Records

FINANCIAL POLICY
I understand fully that, in the event my insurance company or financially responsible party does not pay for the services I receive, I will be financially responsible for payment.

RTM

Medicare Secondary Payor Questionnaire

Home Care Checklist

Concurrent Treatment

Concurrent Treatment

PHYSICAL | OCCUPATIONAL | SPEECH THERAPY CONSENT FOR TREATMENT

General Patient Intake Form

Treatment Location

Personal Information

Emergency Contact

Current Symptoms

Medical History Information

Social History

Home Environment

PHQ-2

ELDER ABUSE SUSPICION INDEX © (EASI)

Within the last 12 months:

WellRX

Referral Information

For our records, list the names and numbers of your doctors:

Document/Image Submission

Insurance Provider/Policies

PATIENT BILL OF RIGHTS

Disclosure of Medical Records

FINANCIAL POLICYI understand fully that, in the event my insurance company or financially responsible party does not pay for the services I receive, I will be financially responsible for payment.

RTM

Medicare Secondary Payor Questionnaire

Home Care Checklist

Concurrent Treatment

Concurrent Treatment

PHYSICAL | OCCUPATIONAL | SPEECH THERAPY CONSENT FOR TREATMENT

FINANCIAL POLICY
I understand fully that, in the event my insurance company or financially responsible party does not pay for the services I receive, I will be financially responsible for payment.