Ferrell Therapy Patient Registration Packet

Therapy Patient Intake Form
Today's Date*

MonthDayYear
Referring Provider's Name
Patient Name*

First NameMiddle NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState

Zip
Home Phone #
Cell Phone #*
Email
Date of Birth*

MonthDayYear
SSN*
Gender*

MaleFemaleOther
Emergency Contact*
Relationship*
Emergency Contact Phone #*
How did you hear about us?*

Doctor ReferralDirect MailFriend/FamilyI've received services here beforeWebsiteGoogle ReviewOther
Do you have a planned or known surgery or inpatient stay scheduled within the next 72 hours?*

YesNo
Have you had any therapy services in the last 12 months?*

YesNo
Is a Home Health Agency currently providing nursing services in your home?*

YesNo
If yes, Name of Home Health Agency*
Is injury related to any of the following?*

WorkAutoOther
Is an attorney involved with your injury?

YesNo
If yes, Attorney's Name*
Attorney's Phone Number*
Responsible Party
Is patient the responsible party?

YesNo
If no, answer the following about responsible party:
Parent/Guardian/Responsible Party Name*
SSN*
DOB*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip
Home Phone #
Cell Phone #*
Work Phone #
Insurance Information
Do you have Medicare?*

YesNo
Insurance Company
Member ID/Policy #
Effective Date

MonthDayYear
Policy Holders Name
DOB

MonthDayYear
SSN
Patient's Relationship to Policy Holder

Work-Related Injury
Date of Injury*

MonthDayYear
Employer Name*
Phone #*
Address*

Street Address

Street Address Line 2

CityState

Zip
Employment Status*

Full TimePart-timeOther
Case Manager Name
Phone #
Fax #
Employer Liability Carrier
Claim #
Address*

Street Address

Street Address Line 2

CityState

Zip
Auto-Related Injury
Auto Insurance Company*
State Accident Occured In*
Date of Accident*

MonthDayYear
Date
Claim/Policy #*
Adjuster/Agent Name*
Phone #*
Were you the...*

DriverPassengerOther

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. APPOINTMENT REMINDER CONSENT

As a way to improve communication and prioritize convenience for patients, this facility utilizes text messaging and email to communicate appointment reminders. I understand that I am not required to authorize the use of text messaging or email in order to receive services from this facility.
Select one option below*

Email MessagesText MessagesI do not wish to recieve text messages or email from this facility
I would like to receive email messages from this facility confirming my upcoming appointments at: Email* .
I would like to receive text messages from this facility confirming my upcoming appointments at the following number, and understand that standard text messaging rates may apply as provided in my wireless plan.

Cell Number for Text Messages: Phone Number*
Carrier Information*

AT&TSprintT MobileVerizonMetro PCSOther
If, so indicated above, I consent to receiving appointment reminders as outlined above. I understand there are risks associated with receiving communications via text message and email because these types of communications are not always secure – emails and text messages can be intercepted. I understand that I have the right to revoke this consent at any time by notifying this facility.

3. 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.
Name
Relationship*
Phone*
Any aspect of my health careHealth information onlyFinancial Information only
Name
Relationship*
Phone*
Any aspect of my health careHealth information onlyFinancial Information only
N/A - None
4. 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.

I authorize this facility and/or its agents to contact me via manual or auto-dial telephone call and/or text in order to collect any amounts I may owe, including calls and texts to my cell phone number, if I have provided that number. I also agree that any email address I have provided is my personal email address and I authorize this facility and/or its agents to contact me via that email address. I understand this facility also utilizes paperless billing as a secure way for patients to view and pay any outstanding charges and I hereby consent and agree to receive statements electronically via the email and/or cell phone number provided by me to the facility. I understand that I can opt-out of paperless billing by selecting the unsubscribe option at the bottom of the email message or by texting "stop" in response to text messages. I understand that there are some risks associated with receiving communications via text message and email because these types of communications are not always secure and can be intercepted.

5. NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT

I have received a Notice of Privacy Practices from this facility.

Click here to read the Notice of Privacy Practices

6. NOTICE OF NON-DISCRIMINATION ACKNOWLEDGEMENT

I have received a Notice of Non-Discrimination from this facility.
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.
Signature of Patient/Representative*
Date*

MonthDayYear
Printed Name*
Relationship to Patient*

Medical History Questionnaire
Patient Name*
Date of Birth*

MonthDayYear
Today's Date*

MonthDayYear
CURRENT CONDITION(S)/CHIEF COMPLAINT(S):
Describe your injury and/or symptoms*
Approximate Date of Injury/Symptoms*

MonthDayYear
What are your goals for therapy?*
What region(s) are affected by your current symptoms?*

Head/NeckUpper BackShoulderArmHand/WristHipPelvisLower BackKneeLegAnkle/FootOther
Where is your injury located?*
PAIN:
Have you had any pain with this injury?*

YesNo
On a scale of 0 (no pain) to 10 (worst pain imaginable), indicate your pain levels over the last 24 hours:

Current: * Best: * Worst: *
PREVIOUS TREATMENTS/TESTS/HOSPITALIZATIONS:
Have you received any previous Physical Therapy, Occupational Therapy, Speech Therapy, or Chiropractic Treatment for this injury?*

YesNo
Have you had any diagnostic tests (MRI, CT Scan, C-Ray, Myelogram, etc) related to this injury?*

YesNo

If yes, list the test(s) and approximate date performed*

	Test	Approximate Date
1
2
3

Have you had surgery related to this injury?*

YesNo
If yes, describe the surgery and date of surgery*
Have you been hospitalized for this injury?*

YesNo
Provide date(s) of hospitalization*

MonthDayYear
MonthDayYear
Please list any other health care professionals whose care you are currently under for this injury
MEDICATIONS:
Please list any medications or supplements you are currently taking
GENERAL HEALTH STATUS:
Do you have a sensitivity to latex that you are aware of?*

YesNo
Are you pregnant or think you might be pregnant?*

YesNo
If yes, estimated due date*

MonthDayYear
Have you fallen within the last year?*

YesNo
How many times have you fallen within the last year?*
At the present time, would you say your health is...*

ExcellentVery GoodFairPoor
Have you had any major life changes during the past year (i.e. new baby, job changes, death of a family member)?*

YesNo
If yes, please explain*
Do you exercise?*

YesNo
If yes, how often?*
What type of exercise?*
Do you have family/community support?*

YesNo
If yes, who?*
MEDICAL HISTORY:
Please check the conditions that you have been or presently are being treated for*

AnginaCOPD/EmphysemaHerniaParkinson's DiseaseAnxiety/DepressionDefibrillator/PacemakerHigh Blood PressurePVDArthritisDiabetesHypoglycemiaSexual DysfunctionAsthmaDizzy or Fainting SpellsImmune System ProblemsSkin AbnormalitiesBack InjuryEpilepsy/SeizuresInfectious DiseaseSmokingBleeding DisorderFractures/Broken BonesKidney ProblemsSpecial DietBowel/Bladder ProblemsGrowth/Develop. ProblemsLiver/Gallbladder ProblemsStomach/GI ProblemsCancerHeadaches/MigrainesMultiple SclerosisStroke or TIAChemical/Substance DependencyHead InjuryMuscular DystrophyThyroid ProblemCHFHearing Problems/RingingNumbness/TinglingVision ProblemsCirculation ProblemsHeart AttackOsteoporosisWeaknessOtherI do not have any medical contitions I am being treated for
If other, please explain
Is there any other information regarding your medical history that is important for us to know?

Ferrell Hospital

CONDITIONS OF ADMISSION AND TREATMENT

I authorize the employees of Ferrell Hospital (FH) to render routine nursing care to me during my admission to FH for medical and/or surgical care, including but not limited to diagnostic and therapeutic tests and procedures (including invasive diagnostic procedures, administration of fluids, blood and any blood products/components, medications, and radiology procedures) and to carry out the orders of my attending physician and the consultants chosen by my physician.

NOTICE OF INDEPENDENT PRACTITIONERS

LEGAL RELATIONSHIP BETWEEN HOSPITAL, PHYSICIANS, AND OTHER HEALTHCARE PROVIDERS - I understand that Physicians and other health care providers furnishing services to me, including but not limited to the Attending Physicians, Consulting Physicians, Surgeons, Radiologists, Pathologists, Emergency Department Physicians, Anesthesia Providers and other medical practitioners are not employees or agents of Ferrel Hospital. The Physicians and other health care providers are independent contractors who have been granted the privlege of using Ferrell Hospital facilities for the care and treatment of their patients. I acknowledge that the employment or agency status of Physicians and other providers who treat me is not relevant to my selection of Ferrell Hospital Community Foundation for my care. I recognize that these Physicians and other health care providers are not subject to the supervision or control of Ferrell Hospital with respect to my treatment and that they exercise their own independent medical judgement.
Initials*

Ferrell Hospital is proud to employ the following medical practitioners:

Amy Allen, FNP
Tiffany Gardney, FNP
Susan Sigler, FNP
Katie Jackson, PA-C
Constance Henshaw, FNP
Joseph A Jackson, MD
Brian Wortel, LCSW
Samantha Mosby, DO
Loni Bank, FNP

Casie Carlile, FNP
Wes Henson, FNP
Melyssa Wiggins, FNP
Lauren Sanders, LCPC
David Gunzel, MD
Nathen E. Oldham, MD
Christopher Moore, DO
Clay Ford, MD

Deborah Davis, FNP
Leslie Ferrell, FNP
Melissa Welge, FNP
Christine Raben, LSW
Luke Hall, MD
Janna R. Pathi, MD
Deborah Sullivan, FNP
Jared Mitchell, MD

Michael Davenport, FNP
Megham Mitchell, FNP
Melissa Gauthier, PA-C
Caleb J. Mitchell, DO
Caitlyn Genet, FNP
Betty German, LCSW
Keely Brown, FNP
Richard Payha, MD

Ferrel Hospital is proud of our affiliation with the following Independent Contractor medical practitioners:

Enrique Campos, MD
Allison Royher, MD
Maqbool Ahmed, MD
Nicholas Oldham, AuD
William J Bose, MD
Holly Wilke, CRNA
Terrence Glennon, MD

Edward Moore, MD
Mark Royer, MD
J Mark Bolind, MD
Troy Sofinowski, MD
Jason Wallette, CRNA
Leighann Ellison, CRNA

Frederick Pfalzgraf, MD
Maj Ahmed, MD
Umesh Jairath, MD
Adeel Siddiqui, MD
Calvin Wientjes, CRNA
Nadia Mostovych, MD

Deane L Smith, MD
Nathan Reed, MD
Dave Chirag, MD
Ukeme Umana, MD
Randy Wientjes, CRNA
Dennis Beck, MD

Further, I realize that among those who attend FG are medical, nursing, and other health care personnel in training who, unless I direct otherwise in writing, may be present during patient care of their education.
I acknowledge any questions about the Independent Contractor Disclosure form and the important information contained in it have been answered to my satisfaction.

Initials*
Valuables / Personal Items - I agree to deposit money, jewelry, and other valuables with FH for safekeeping or to send them home. If I choose to keep any such valuables or any personal items such as dentures, eyeglasses, contact lenses, etc., I assume full responsibility for them.

Insurance Coverage - I authorize any insurance company or organization to pay benefits directly to Ferrell Hospital and this consent is my assignment of benefits to FH.

NOTIFICATION CONCERNING OUT OF NETWORK PROVIDERS - As a patient, I understand that I may receive separate bills for services provided by health care officials affiliated with FH. Some hospital staff members may not be participating providers in the same insurace plans and networks as FH. As a result, I may have a greater financial esponsbility for services provided by health care professionals at FH who are not under contract with my health care plan. I further understand that I should contact my health care plan and/or certificate of coverage with any questions that I have regarding my insurance coverage or benefit levels.

Financial Responsibility - I understand that regardless of my assigned insurance benefits, I am repsonsible for the total charges for sevices rendered, and I further agree that all amounts are due upon request and are payable to FH. I further understand that should this account become delinquent and it becomes necesary for the account to be transferred to an attorney or collection agency or suit, the designated responsible party and I shall pay the reasonable attorney fees or collection expenses.

Statement of Non-Discrimination - PH provides services to all persons without regard to race, color, national origin, handicap or age, in compliance with CR Parts 80, 84, and 91 respectively.
Consent Under the Telephone Consumer Protection Act - By signing and/or initialing below, I hereby expressly consent to Ferrell Hospital and/or any of its agents and/or asignees (including, but not limited to HSC Medical Billing and Consulting, Progressive Rehab, CBSI, Jay Unmansky Law Firm, and/or any other collection agents) (collectively, the "Collection Parties"): (a) attempting to contact me by means of an automatic telephone dialing system or otherwise at any telephone number(s) that I have provided or may provide to one or more of the Collection Partied or that said Collection Parties may otherwise obtain for me (collectively, the "Authorized Telephone Numbers"); (b) leaving on or otherwise communicating to any Authorized Telephone Numbers and live and/or prerecorded messages regarding any amounts owing by me to any of the Collections Parties; and (c) contacting me by email at any email address (private or otherwise) that I have provided or may provide to any of the Collection Parties. I understand and acknowledge that it is not a condition to my receiving services and/or treatment that I provide this consent and/or furnish any telephone number, cellular number, or email address to any of the Collection Parties.
Initials*
Patient requested/offered interpreter?

YesNoRefusedN/A
Interpreter arrangements made by
on Date

MonthDayYear
Date
Patient has own interpreter?

YesNoN/A
I certify:
1. That I have read or have had this consent read to me;
2. That I was given an opportunity to ask any questions;
3. That all questions were answered to my satisfaction; and,
4. That I understand this consent and accept its terms and conditions.
Signature of Patient or Personal Representative/Agent*
Printed Name of Personal Representative/Agent
Relationship to Patient*

SelfStepfatherSpousePower of AttorneyMotherDCS Case WorkerFatherOtherGuardianNoneStepmother

NOTICE OF NO SHOW POLICY ACKNOWLEDGEMENT
Name*
Date of Birth*

MonthDayYear
Due to the limited time slots for clinic appointments, it is important that all patients attend their scheduled appointments. If you are 15 minutes LATE your appointment will be rescheduled. If you are unable to attend, it is expected that you call and inform Ferrell Therapy 618-273-2327 in a timely manner. If you DO NOT cancel your appointment in a timely manner, or do not SHOW UP for your appointment, this is considered a NO SHOW.

As a policy, if you have 3 or more NO-SHOWS, we reserve the right to discontinue therapy services. Thank you for your understanding in this matter.

I have read and understand this policy.
Signature*
Date*

MonthDayYear

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By signing below, I hereby acknowledge receipt of Ferrell Hospital's Noticy of Privacy Practices and consent to the uses and disclosures described in the Notice of Privacy Practices.
Name of Patient*
Signature of Patient or Personal Representative*
Date of Signature*

MonthDayYear
Date

MEDICARE SECONDARY PAYER QUESTIONNAIRE
Patient Name*
Medicare Number*
Symptoms Start Date*

MonthDayYear
Date
Date of Visit*

MonthDayYear
Date
Filled Out By*
Relationship to Patient*
1. Is this illness/injury covered under the Federal Black Lung Program?*

YesNo
Date coverage began*

MonthDayYear
2. Is treatment for this illness/injury authorized by the Veteran's Administration?*

YesNo
3. Is this illness or injury due to a work related accident/condition?*

YesNo
Employer Name & Address*
4. Is this illness/injury covered under no-fault or automobile insurance?*

YesNo
5. Is this an illness or injury for which another party could be held liable?*

YesNo
6. Is patient insured by an employer group health plan due to current employment of self?*

YesNo
Date coverage began*

MonthDayYear
If yes, how many employees work for the sponsoring employer?*

Don't know1-1920-99100 or more
7. Is patient insured by an employer group health plan due to current employment of spouse or other family member?*

YesNo
Date coverage began*

MonthDayYear
If yes, how many employees work for the sponsoring employer?*

Don't know1-1920-99100 or more
8. Is patient under 65 and entitled to Medicare due to disability?*

YesNo
Is patient insured by an employer group health plan?*

YesNo
9. Is patient entitled to Medicare due to End Stage Renal Disease (ESRD)?*

YesNo
Is patient insured by an employer group health plan?*

YesNo
Is patient within the 30-month coordination period?*

YesNo
10. If applicable, attorney's name and address
11. Are you a member of a Medicare health maintenance organization (HMO) program?

YesNo
12. Have you been hospitalized in the past 60 days?

YesNo
If yes, when and where?*

You have completed your patient registration forms.

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