• Therapy Patient Intake Form

  • Today's Date*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Cell Phone Carrier:*
  • Date of Birth*
     / /
  • Gender*
  • Format: (000) 000-0000.
  • How did you hear about us?*
  • Do you have a planned or known surgery or inpatient stay scheduled within the next 72 hours?*
  • Have you had any therapy services in the last 12 months?*
  • Is a Home Health Agency currently providing nursing services in your home?*
  • Is injury related to any of the following?*
  • Is an attorney involved with your injury?
  • Format: (000) 000-0000.

  • Responsible Party

  • Is patient the responsible party?

  • If no, answer the following about responsible party:

  • DOB*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance Information

  • Do you have Medicare?*
  • Effective Date
     / /
  • DOB
     - -

  • Work-Related Injury

  • Date of Injury*
     / /
  • Format: (000) 000-0000.
  • Employment Status*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Auto-Related Injury

  • Date of Accident*
     - -
  • Format: (000) 000-0000.
  • Were you the...*

  • Outpatient Therapy Department

    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*

  • I would like to receive email messages from this facility confirming my upcoming appointments at:   *  .

  • 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:         *   

  • Carrier Information*

  • 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.

  • 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.

  • Format: (000) 000-0000.
  • *
  • Format: (000) 000-0000.
  • *

  • 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.

  • Date*
     - -

  • Medical History Questionnaire

  • Date of Birth*
     / /
  • Today's Date*
     / /

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

  • Approximate Date of Injury/Symptoms*
     / /
  • What region(s) are affected by your current symptoms?*

  • PAIN:

  • Have you had any pain with this injury?*

  • 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?*
  • Have you had any diagnostic tests (MRI, CT Scan, C-Ray, Myelogram, etc) related to this injury?*
  • Rows
  • Have you had surgery related to this injury?*
  • Have you been hospitalized for this injury?*
  • Provide date(s) of hospitalization*
     - -
  •  - -

  • MEDICATIONS:

  • GENERAL HEALTH STATUS:

  • Do you have a sensitivity to latex that you are aware of?*
  • Are you pregnant or think you might be pregnant?*
  • If yes, estimated due date*
     / /
  • Have you fallen within the last year?*
  • At the present time, would you say your health is...*
  • Have you had any major life changes during the past year (i.e. new baby, job changes, death of a family member)?*
  • Do you exercise?*
  • Do you have family/community support?*

  • MEDICAL HISTORY:

  • Please check the conditions that you have been or presently are being treated for*
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  • 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.

    In consideration of a Deaconess Health System, Inc. affiliate, including but not limited to Deaconess Hospital, Inc., Deaconess Clinic, Inc., Deaconess Specialty Physicians, 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, Deaconess Memorial Medical Center, Inc. (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 have in 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 assistance is needed. 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. I/we authorize Deaconess to procure a consumer report on me/us if applicable.

    If I/we provide Deaconess or its agents with our cell phone number, I/we authorize Deaconess or its 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.

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

    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 and to inform Deaconess of any applicable coverage at the time of service. The patient should be aware that if the patient does not provide this information timely or these claims are denied for failure to notify, the balances will then become the patient’s responsibility. Payment of deductibles, non-covered services and co-payments are the patient’s responsibility.

    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.

    I have received a Notice of Nondiscrimination.

    Click here to read the Notice of Nondiscrimination

     

  • Date*
     / /

  • NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

    I have received a Notice of Privacy Practices from Deaconess.

    Click here to read the Notice of Privacy Practices

  • Date*
     / /

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

  • MEDICARE SECONDARY PAYER QUESTIONNAIRE

  • Symptoms Start Date*
     - -
  • Date of Visit*
     - -
  • 1. Is this illness/injury covered under the Federal Black Lung Program?*
  • Date coverage began*
     / /
  • 2. Is treatment for this illness/injury authorized by the Veteran's Administration?*
  • 3. Is this illness or injury due to a work related accident/condition?*
  • 4. Is this illness/injury covered under no-fault or automobile insurance?*
  • 5. Is this an illness or injury for which another party could be held liable?*
  • 6. Is patient insured by an employer group health plan due to current employment of self?*
  • Date coverage began*
     - -
  • If yes, how many employees work for the sponsoring employer?*
  • 7. Is patient insured by an employer group health plan due to current employment of spouse or other family member?*
  • Date coverage began*
     - -
  • If yes, how many employees work for the sponsoring employer?*
  • 8. Is patient under 65 and entitled to Medicare due to disability?*
  • Is patient insured by an employer group health plan?*
  • 9. Is patient entitled to Medicare due to End Stage Renal Disease (ESRD)?*
  • Is patient insured by an employer group health plan?*
  • Is patient within the 30-month coordination period?*
  • 11. Are you a member of a Medicare health maintenance organization (HMO) program?
  • 12. Have you been hospitalized in the past 60 days?

  • You have completed your patient registration forms.

    To review your responses, click Preview PDF.  To submit without reviewing, click Submit.

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