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. 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.

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.

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. ASSIGNMENT OF BENEFITS

This facility will file my insurance claims as a courtesy, and I understand that any quoted benefits provided at the time of service are not a guarantee of payment. I assign all insurance benefits to be paid directly to this facility. I understand that I am ultimately responsible for the charges incurred for my services at this facility that are not covered by my insurance.

I understand that additional information may be required of me to assist this facility in filing such claims, and I agree to provide this information as requested, including but not limited to:
○ Social Security Number
○ Date of Birth
○ Copy of Insurance Card (for commercial filing and/or worker’s compensation)
○ Name of employer, employer address, phone number and contact person
○ Auto Insurance

6. 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. If you must cancel within 24 hours of your appointment or fail to show up for your appointment, a $40 fee will be applied to your account, which will be patient responsibility and is not billable to insurance. This facility also reserves the right to cease rescheduling new appointments due to habitual no shows or cancellations and 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.

7. 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

8. NOTICE OF NON-DISCRIMINATION ACKNOWLEDGEMENT

I have received a Notice of Non-Discrimination from this facility.

Click here to read the Notice of Non-discrimination

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:

PAIN QUESTIONNAIRE

MEDICARE SECONDARY PAYER QUESTIONNAIRE

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