Adult Patient Registration Form

  • Adult Patient Registration Form

  • Date*
     - -
  • Is Patient Under the Age of 18
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Is patient receiving any type of Home Care Services?*
  • Do you have traditional Medicare? If so, Medicare requires us to ask a few additional questions.
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  • Medicare Payer (MSP) Information

  • Please answer questions 1 through 7 if you receive Medicare benefits (Part A, Part B or Disability).

    As a direct result of mandated Medicare Secondary Payer (MSP) regulations, Crane Rehab Center is required to gather the following information to determine if Medicare is your primary insurance:

  • 1. Is illness/injury due to an automobile, liability, or worker's compensation accident?*
  • 2. Is illness covered by the Black Lung Program or Veterans*
  • 3.If under age 65, are you a renal dialysis patient in your first 12 months of Medicare entitlement?*
  • 4. If under age 65, is your Medicare coverage due to disability?*
  • 5. Is patient covered by an Employer Group Health Plan through patient's employer or spouse's or family*
  • 7. Does the patient have supplemental coverage?*

  • HOME CARE SERVICES

  • Is patient receiving any type of Home Care Services?*
    • Self-Pay Agreement 

    • ACKNOWLEDGMENT OF SELF–PAY STATUS
      By signing this form, I agree to pay for my therapy services myself and I hereby remove Crane Rehab from the
      responsibility of billing my insurance carrier, if applicable.

      We at Crane Rehab want you to make an informed decision regarding our self-pay rules and regulations.

      By signing below, you agree to the following:
      • Payments for all services and supplies are due at the time of service.
      • Crane Rehab Center, LLC will not retroactively submit a claim to an insurance provider for services rendered.
      • At any time per your request, we can provide you with a patient statement for you to submit to your insurance or for tax purposes. Please note that some insurance carriers require authorization prior to services being rendered and may not accept a self-pay statement. You may want to discuss this with your
      insurance carrier before agreeing to the self-pay discount.

      PATIENT AGREEMENT
      I agree to pay personally for therapy services and elect not to have my insurance billed. I agree to be personally and fully responsible for any and all charges accrued related to the delivery of therapy treatments. I understand that I may not go back and choose to have a previous session switched from self-pay to insurance
      billed charges. It is my right to request future sessions be billed through insurance, but I am responsible for communicating that request in writing to Crane Rehab. I understand and agree to the above stated terms. I understand that insurance filing is done as a courtesy to me, and I have chosen to opt out of this option.

      By signing below, I acknowledge that I have read and understand the above and have been given the opportunity to ask questions. I confirm that I am the legal guardian, or the legal guardian's duly authorized representative.

    • Date
       - -

  • Medical History

  • Have you RECENTLY noted any of the following? Check all that apply:
  • Have you EVER been diagnosed with any of the following conditions?
  • Have you relied on anyone for your daily activities (bathing, dressing, meals, etc)?*
  • Do you smoke*
  • Are you pregnant or think you might be pregnant?*
  • Are you latex sensitive?*
  • Rows

  • CRANE REHAB CENTER INTAKE NOTICES ACKNOWLEDGMENT

    Upon request, these notices can be emailed and are also available at the front desk of every Crane Rehab Center location.

    I acknowledge that I have read, understand, and have been provided with a copy of the following
    notices:
    • INSURANCE INFORMATION
    • TREATMENT CONSENT & AUTHORIZATION
    • AUTHORIZATION TO RELEASE INFORMATION
    • ASSIGNMENT OF BENEFITS
    • PAYMENT GUARANTEE
    • INSURANCE, INDEMNITY INSURANCE, AND OTHER THIRD-PARTY LIABILITY CLAIMS
    • NOTIFICATION OF INSURANCE CHANGES
    • MISSED APPOINTMENT POLICY: 24 HOUR NOTICE AND CANCELLATION/NO SHOW FEE
    • ELECTRONIC COMMUNICATION, ACKNOWLEGDEMENT & AGREEMENT
    • PATIENT’S RIGHT TO CHOOSE PROVIDER
    • DISCONTINUATION OF SERVICES
    • LEARNING/EDUCATION SITE
    • PERSONAL PROPERTY
    • HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (1996)
    • NOTICE OF PRIVACY POLICY (NPP) AND PRACTICES FOR PROTECTED HEALTH INFORMATION


    By signing below, I confirm that I have had the opportunity to ask questions regarding these policies and that I fully understand the information provided. I acknowledge that I am voluntarily agreeing to abide by these rules and regulations during my treatment and care at Crane Rehab Center.

  • Date
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  • Should be Empty: