Therapy Patient Intake Form

Responsible Party

Insurance Information

PATIENT AUTHORIZATION AND CONSENT FORM

1.   CONSENT FOR TREATMENT

I consent to treatment rendered by this facility which may be ordered or approved by my physician or other qualified and licensed health care provider who is responsible for my care. I agree to participate in this facility’s program to the best of my ability to facilitate a rapid and full recovery.

I understand that some increase in pain may be normal. I must determine how much pain increase is acceptable to me. I may be asked to describe my pain using a Visual Analog Scale. I will not be asked to perform activities that increase my pain to a level that is unsafe or undesirable to me. I will be asked to perform activities, but will not be forced to perform any activity that I believe unsafe. I will be informed if I am seen doing anything unsafe or that jeopardizes my recovery.

I understand that medical care is not an exact science and there is no guarantee that the treatments or program provided will have a good result. I understand that the therapists and health care staff providing care and treatment will use their best judgment. I understand that I have the right and responsibility to participate in decisions affecting my treatment.

I consent to having my picture taken for objective analysis of my condition. This information will be used solely for the purpose of education of myself for my condition and to compare pre and post treatment outcomes. Any other use of this information will require my written consent.

2.   AUTHORIZATION FOR DISCLOSURE

I, a patient of this facility, give my express permission for this facility and its agents to discuss the information I have specifically indicated below with the following individuals. I understand that I am responsible for notifying this facility, in writing, of any changes to this authorization to disclose my personal health information.

3. PAYMENT AT TIME OF SERVICE POLICY

As a standard practice, this facility collects all expenses that are the responsibility of the patient at the time of service. This request for payment will include any deductible, co-pay and coinsurance amounts that apply to my visit. I understand that as a courtesy this facility will bill my insurance directly for the services I receive, but this is not a guarantee that my insurance will pay for services rendered or materials received. It is my responsibility to know my insurance benefits and coverage.

In some cases, the amount of charges is an estimate based upon information provided directly by my insurance company regarding my particular plan and eligibility and the procedures performed. However, the exact amount of all charges may not be known at the time of service as my insurance may process differently than anticipated. It is possible that additional expenses that are my responsibility may be reflected on my final statement. In such a case, the payment collected at the time of service serves as a deposit towards my final balance. Additionally, any overpayment will be promptly refunded to me after all claims have been processed by all applicable payers.

In the event that there is a past due balance on my account, it will be submitted to a collection agency, and I agree to pay all attorneys' fees and court costs incurred by this facility in the collection of my account.

I understand that if I anticipate problems paying my portion of my bill, I should let the front office know as soon as possible, so that payment alternatives may be discussed, should I qualify.

4.   PATIENT COMMUNICATIONS

The facility and its agents may contact me by live telephone call regarding appointments, care coordination, billing, and other administrative or service-related matters as necessary to provide care and operate the practice. To improve communication and convenience, this facility and its agents may also contact me by text message, automated or prerecorded phone call, and/or email regarding these matters, which may include limited protected health information. By providing my mobile phone number and/or email address, I authorize the facility and its agents to contact me using these methods, including for electronic (paperless) billing and statements. I understand that standard message or data rates may apply and that text and email communications may not be fully secure. I understand that I am not required to consent to these electronic communications to receive care and that I may opt out at any time by using the available electronic opt-out option or by contacting the facility directly. I understand that opting out will not affect live telephone calls necessary for care or billing.

5. CANCELLATION / NO-SHOW POLICY

We strive to provide not simply good, but absolutely the best care to our clients. We schedule our clients according to care plans that optimize their wellness outcomes. Making your appointment as scheduled is very important, not just for us, but for you. We are convinced that if you make your wellness a life priority, you will achieve not only a higher level of function, but a greater degree of happiness.

We have the most highly trained and experienced clinicians in the region. You are working with the best. Their services and time are in high demand, with waiting lists for many of their services. As you know, we attempt to schedule all new clients within 24-48 hours of their initial request for service. Thus, appointment time is a valuable commodity for both you and us.

If negative circumstances require you to cancel a scheduled appointment, we request that you do so at least 48 hours in advance. This facility reserves the right to cease rescheduling new appointments due to habitual no shows or cancellations and also reserves the right to discharge any patient who fails to give proper notice three (3) consecutive times.

While we are not fond of the negative connotation of any cancellation policy, we believe such a policy is in the best interest of accommodating all of our clients who are dedicated to improving their wellbeing. Thank you for your consideration.

I acknowledge that I have read the above Patient Authorization and Consent Form or have had it read to me, and that I understand and agree to all of the information and terms above.

Medical History Questionnaire

CURRENT CONDITION(S)/CHIEF COMPLAINT(S):

PAIN:

PREVIOUS TREATMENTS/TESTS/HOSPITALIZATIONS:

MEDICATIONS:

GENERAL HEALTH STATUS:

MEDICAL HISTORY:

Thank you for choosing Deaconess. Our goal is to provide you with quality medical services. Your clear understanding of our financial policy is important to our professional relationship. Please understand that payment of your bill is vital to our ability to continue to provide medical care within the community. We accept Cash, Check, Visa, MasterCard and Discover.

ALL ACCOUNTS

In consideration of a Deaconess Health System, Inc. affiliate, including but not limited to Deaconess Hospital, Inc., Deaconess Clinic, Inc., Methodist Health, Inc. d/b/a Deaconess Henderson Hospital, Deaconess Union County Hospital, Inc., and Gibson General Hospital, Inc. d/b/a Deaconess Gibson Hospital, Deaconess Women's Hospital of Southern Indiana, LLC d/b/a The Women's Hospital (collectively "Deaconess"), rendering services for the above named patient, I/we, the undersigned, and each of us, agree to be jointly and severally responsible for payment for these services and any other account that the patient had at any time in the past, at the present, or may havein the future with Deaconess. I/we agree that the charges for which I/we are responsible will be calculated according to Deaconess's Chargemaster and I/we agree to pay those Chargemaster rates. All accounts are due and payable at the time of the patient's discharge. Any credit will be applied to outstanding balances prior to being refunded. Please contact the Deaconess Financial Counseling Services at 812-450-6815 if you need assistance. Past due patient accounts that do not have agreed upon financial arrangements with Deaconess will be submitted to a collection agency or attorney for collection. I/we agree that I/we will pay all attorney fees and court costs incurred by Deaconess in the collection of all sums due Deaconess.

COMMUNICATIONS

If I/we provide Deaconess or its agents with our cell phone number, I/we authorize Deaconess or it agents to contact us at that cell phone number by calling or text messages, which could result in charges to me. I/we authorize Deaconess to contact us on our cell phone number by using pre-recorded artificial voice messages and/or use of an automatic dialing device. I/we understand that any e-mail address I/we provide is our personal e-mail address and I/we authorize Deaconess or its agents to contact us via that e-mail address.

WORKER'S COMP / LIABILITY / AUTO ACCIDENT

If the reason for your visit is related to a worker's comp claim, liability claim, or auto accident, you are responsible for providing Deaconess with complete billing information, including police report, claim number, etc. as appropriate, within seven (7) business days. You should be aware that if you do not provide this information or these claims are denied, the balances then become the patient's responsibility.

INSURANCE

If the patient has active insurance coverage, we will bill the patient's insurance company. It is the patient's responsibility to understand his/her insurance coverage. Payment of deductibles, non-covered services and co-payments are your responsibility.

ASSIGNMENT OF INSURANCE BENEFITS

I/we assign insurance payments to be made directly to Deaconess for services rendered.

I/we have read, understand and agree to the terms listed above.

NOTICE OF NONDISCRIMINATION

I have received a Notice of Nondiscrimination.

Click here to read the Notice of Nondiscrimination

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I have received a Notice of Privacy Practices from Deaconess.

Click here to read the Notice of Privacy Practices

(May only be signed by patient, guardian, power-of-attorney, health care representative, or, if minor child, parent)

MEDICARE SECONDARY PAYER QUESTIONNAIRE

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