• Wellspring Health Center

    Work Injury Intake Form

  • Please note, this form typically takes 10-20 minutes to complete, and partial submissions are not accepted. Please ensure you have adequate time to complete the entire form before beginning.

    If you prefer to print and complete this form, please download it here: PRINT FORM

    If you prefer to complete this form in our office, please arrive 10-15 minutes early for your appointment.

    Thank you and we can't wait to meet you!

  • Date of Birth*
     / /
  • Today
     / /
  • Sex:*
  • Primary Contact Phone #:*
  • Format: (000) 000-0000.
  • How did you hear about our office?*
  • Format: (000) 000-0000.
  • Do you have a primary care physician?*
  • Has the injury been reported to your employer?*
  • Do you have a worker's compensation claim number yet?*

  • We understand it can take some time to get your claim information, and we are happy to see you for a consultation in the meantime.

    However, since some worker's compensation carriers require prior authorization for physical therapy, we may not be able to begin treatment until the claim information is provided.

    Please bring in or send in your information as soon as you get it to ensure that we can obtain authorization and start treatment as soon as possible.

    Claim information can be sent to us at info@wellspring-hc.com or faxed to 952-930-3304.

  • Format: (000) 000-0000.
  • Date of Injury:*
     / /
  • Have you lost any time from work due to your injury?*
  • Have you had any previous worker's compensation claims?*
  • Quality of symptoms:*
  • Do your symptoms radiate?*
  • When do you notice your symptoms?*
  • Tests you've had for this condition:*
  • Do you smoke cigarettes?*
  • Do you consume coffee?*
  • Do you consume soda?*
  • Do you consume alcohol?*
  • What is your stress level?*
  • Work activity involves:*
  • Are you right or left handed?*
  • Are you pregnant?*
  • Due Date*
     / /
  • Rows
  • Rows
  • Are you currently taking any medications?*
  • Rows

  • Review of Systems:

    Have you experienced any of the following in the LAST FEW MONTHS? Please select as many as apply, or select "NONE"
  • General*
  • Headaches*
  • Eyes*
  • Ear/Nose/Throat*
  • Skin*
  • Cardio*
  • Lungs*
  • GI*
  • GU/GYN*
  • Neuro*
  • Musculoskeletal*
  • Hemo*
  • Endocrine*
  • Is there a history of any of the following conditions in your family?

  • CONSENT FOR DISCLOSURE OF INFORMATION:

  • Our clinic has always been very protective and respectful of your personal information. Under the HIPAA Privacy Act we have adopted additional guidelines to ensure the proper use, confidentiality and disclosure of your health information.

     

  • I give the clinic permission to leave a message on my voicemail/answering machine:*
  • I give the clinic permission to discuss my medical condition with another person:*
  • If yes, who do you give the clinic permission to discuss your medical condition with?*

  • Consent For Treatment

    I hereby give consent to the healthcare providers of Wellspring Health Center, PLLC to render such care and treatment as might be required by my condition. Such care may include, but is not limited to consultations, examinations, digital x-rays, rehabilitative physical therapy, medical treatment, massage, wellness or maintenance care.

  • HIPAA Privacy Policies: Consent for Use and Disclosure of Health Information

    I acknowledge that I have been made aware of the clinic’s privacy policies and may request a copy at any time. The policies are available in our reception area and on our website at www.wellspring-hc.com.

  • Payment policy

    We will file claims with contracted and approved insurance plans as a courtesy. The clinic has the right to not accept non-contracted insurance plans at its discretion and in these cases; charges for services rendered are to be paid at the time of service, unless other arrangements have been made in advance. I understand that if I have not listed any insurance plan that I am responsible for the full amount of the visit unless other arrangements have been made in advance. Please note that affordable payment options and financial hardship plans are available if needed.

    I understand that I am financially responsible for all charges whether or not paid by insurance, unless other arrangements have been made in advance. Any unpaid patient balance will accrue a 1 ½% monthly billing charge after 90 days. Any collection fees, attorney fees, or returned check fees are the responsibility of the adult person(s) named on the account.

  • Assignment of Insurance Benefits

    I certify that I or my dependents have insurance through the insurance company information that I have provided and assign directly to Wellspring Health Center, PLLC all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

    In the event that my insurance company forwards payment directly to me, instead of Wellspring Health Center, PLLC, I will immediately deliver said payment to Wellspring Health Center, PLLC.

    I also verify that all the information contained on the history forms is true and correct to the best of my knowledge and belief. I authorize Wellspring Health Center, PLLC to release my complete records to its business management company and/or to my insurance carrier(s) and or agents to secure payment of benefits; I also authorize Wellspring Health Center, PLLC designation of representation for insurance claims appeals.

  • Release of Records

    I authorize the release of my complete records to or from other physicians or medical facilities that may be pertinent and necessary to my care and treatment.

  • Date*
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  • Should be Empty: