Intake Form

Intake Form

IMPORTANT: Completion of this intake form is required for all patients, new and returning, for each case. This form must be completed by the patient or the designated responsible party only. All information is kept strictly confidential.
Patient Full Name

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Who is filling out this form?
What is your name?
Include first and last
What is your relationship to the patient?
Include your relationship to the patient
Patient Type
Please Select
Who will be the primary contact moving forward
Please select for communication preferences
Primary Contact Phone
Please enter a valid phone numberFormat: (000) 000-0000.
Primary Phone Type
Primary Contact Email
Please enter a valid email address.
Has your insurance, address, or contact information changed?
Secondary Contact Name
Cannot be duplicate of primary contact
Secondary Contact Relation to Patient
Please describe secondary contact's relation to the patient
Secondary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Type
Secondary Contact Email
Appointment Reminder Type
Appointment Reminders are Mandatory
Emergency Contact (cannot be primary/secondary contact)
Name, Relation to Patient, Phone Number
How did you find out about Mizuta & Associates Physical Therapy?

Other
We may need to contact your provider to obtain a copy of your physical therapy referral and/or fax your PT notes for signature. Please list your referring provider's name.
Note: Medicare requires a PT referral on file.
Please provide your referring doctor's contact info if available.
Phone, Fax, Email
Please list your primary care doctor if you would like us to send your notes to your PCP.
Please provide your PCP's contact info if available
Phone, Fax, Email
Patient Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Please select Sex
Please list gender
Medical History
What is the primary reason for your visit (injury, accident, condition)?
Please include date of injury, onset, or date of related surgery.
Are you currently taking any medications?

Have you had any orthopedic surgeries?
If yes, please list type of orthopedic surgeries and dates
Please indicate if you have or have had any of the following health conditions:
Are you currently pregnant?
Do you use tobacco products?
Please list anything else you feel the physical therapist should know about your medical history
Which Physical Therapist will be working with the patient?
Scroll through list to find PT
Ericka Mizuta Residential Facility

All the rest of our therapists treat patients in home. Ericka is the owner and is the only exception as she treats patients out of her residential facility in Serra Mesa.
Parking Instructions - list any details your therapist should know in advance
(i.e. gate code, check in with front desk, designated parking area, etc)
Cancellation Policy

Mizuta & Associates Physical Therapy will assess fees for the following conditions:
I agree to provide at least 24 hours notice for any appointment cancellations or rescheduling, or I may be subject to a cancellation fee.
Billing
Payment Type

Self-Pay Option

Cash-Based Care
By selecting the Cash / Self-Pay option, you are choosing to move forward without using insurance and instead take advantage of our straightforward self-pay rates.

All sessions are one-on-one with a licensed physical therapist and are just under one hour in length, allowing for personalized, focused care.

Standard Rates
Initial Evaluation $175
Follow - Up Visits: $150

Package Options (Set amount of visits paid up front)
5 visits: $675 ($135 per visit)
10 visits: $1,250 ($125 per visit)

Package options are expected to be paid in advance. However, if you prefer to decide after your initial evaluation, package payment is due no later than the day following your first visit.

To ensure your preferred package rate is applied, we ask that you notify our billing coordinator in advance so your invoice can be prepared accordingly. If a package is not selected within this timeframe, visits will be billed at the standard rates.

*To secure a package option, please email Mary at mary@mizutapt.com
Self-Pay Assignment & Release
I understand and accept full financial responsibility for all services at the standard self-pay rates. I understand that I must notify the billing coordinator in advance to utilize package pricing or request an adjusted invoice.

Insurance Type
We are not contracted with any HMO policies

Medicare Part B Patient Acknowledgement

For patients with Original/Traditional Medicare
Understanding Medicare Coverage

Medicare Part A generally covers hospital stays, skilled nursing facilities, hospice care, and home health services. Medicare Part B covers outpatient care, including physical therapy services provided by Mizuta & Associates Physical Therapy.

When Financial Liability Will Apply

If you are receiving services covered under Medicare Part A, such as home health nursing or therapy visits, while also receiving outpatient physical therapy from Mizuta PT under Medicare Part B, Medicare regulations require that Part A takes precedence.

If you are discharged from the hos pital and begin receiving home health visits, (for example nursing, wound care, or therapy in the home) or if another physical therapist, nurse, or occupational therapist visits the home for treatment, Medicare will recoup payments previously made to Mizuta PT for outpatient therapy.) In those cases, you are responsible for those visits.

Patient Responsibility

If Medicare recoups payments due to overlapping home health services, you will be responsible for the visit charge of $130 per session.

Communication is Key

Please notify Mizuta PT immediately if any provider other than the Mizuta therapist begins providing care in the home so we can coordinate care and pause outpatient services if needed until home health care is completed.

Secondary or Supplemental Coverage

Medicare typically pays 80% of approved charges after your annual deductible is met. The remaining 20% coinsurance ($23 per visit) is your responsibility unless a secondary or supplemental plan covers it.

Some secondary plans do not cover the Medicare deductible but will cover the 20% once the deductible is met. Because coverage varies by plan, you are responsible for knowing your benefits and how your plan coordinates with Medicare.
Please Indicate whether you have a secondary or supplemental insurance:
It’s important that your benefits are properly coordinated with Medicare so your claims automatically forward (“crossover”) to your secondary plan. This helps prevent delays and avoidable denials.

Patient Responsibility

Having a secondary or supplemental insurance plan does not guarantee full payment. Even when Medicare or your secondary plan is in place, you may still be responsible for deductibles, coinsurance, denied amounts, or non-covered services if either plan does not pay in full.

Why This Matters

We frequently see secondary plans deny payment for reasons like “no claim on file,” “claim not received,” or other administrative issues when we must send the claim manually (i.e., when Medicare crossover is not set up). When crossover is active, Medicare transmits your claim directly to your secondary insurer and these denials are uncommon. If crossover is not set up, we must submit the secondary claim manually—which requires batching, printing, scanning, and mailing a full billing packet.

Our Courtesy & Your Responsibility

We will manually submit your secondary claims as a one time courtesy if needed. If the secondary does not pay within 45 days of that submission, you will be responsible for the Medicare 20% coinsurance, which is $23 per unpaid visit. We will email you the billing packet we mailed to your secondary so you can follow up directly with your secondary insurance for reimbursement.

To ensure Medicare crossover is set up

1. Contact your secondary insurer (e.g., AARP, Blue Cross, Cigna, etc.)

2. Ask them to submit a Coordination of Benefits (COB) to update Medicare so that Medicare forwards your claim info to your secondary for payment

3. You will need to call Medicare’s Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627 to make sure the COB was recieved.

*For more information, visit: CMS Coordination of Benefits Overview (cms.gov)
Home Health & Medicare Policy
Medicare Crossover Acknowledgement

I have read and understand it is my responsibility to ensure Medicare crossover to my secondary insurance. I understand that having a secondary or supplemental insurance plan does not guarantee full payment. If Medicare or my secondary/supplemental plan leaves a deductible, coinsurance, denied amount, non-covered service, or any other unpaid balance, I may be responsible for that amount. I understand that if crossover is NOT set up, Mizuta & Associates will submit secondary claims once manually and that unpaid claims after 45 days are my responsibility for the 20% Medicare coinsurance ($23 per visit).

Insurance Participation
- Mizuta & Associates Physical Therapy is in-network with Medicare, TRICARE, and the Department of Labor. We are considered out-of-network with all PPO plans, including (but not limited to) Blue Cross, Blue Shield, Aetna, UnitedHealthcare (UHC), Cigna, Humana, and GEHA. If your policy includes out-of-network benefits, our team will gladly verify your coverage and help you understand any potential financial responsibility prior to starting care. Please note, we are not contracted with any HMO plans.
- Insurance Estimates & Patient Responsibility
  
  Mizuta & Associates Physical Therapy is an out-of-network provider for all PPO plans. This means services are billed to your insurance on your behalf, but reimbursement is based on your individual out-of-network benefits.
  
  If your plan includes a deductible, please note that you may be responsible for the full cost of care until that deductible is met. As we submit claims that apply towards your deductible, visits are billed to the patient at our standard rates:
  
  Initial Evaluation: $175
  Follow-Up Visits: $150
  
  Once your deductible has been satisfied, your insurance may begin to apply coinsurance toward services, based on your specific plan benefits.
  
  As a courtesy, we verify benefits and provide an estimate of your expected financial responsibility. However, these estimates are not a guarantee of payment. Final responsibility is determined by your insurance carrier once claims are processed. It is ultimately your responsibility to understand your coverage, notify us of any changes, and pay any copays, coinsurance, deductibles, noncovered services, or other patient-responsible amounts.
  
  For patients who anticipate needing multiple visits prior to meeting their deductible, we offer discounted package options for prepayment. If you are interested in a package, please contact the billing coordinator, Mary, at mary@mizutapt.com prior to scheduling or treatment so we can assist you.
  
  You may receive an Explanation of Benefits (EOB) from your insurance company. If you were quoted an estimated patient responsibility, we will not bill more than that estimate as long as we receive the expected payment directly from your insurance. Estimates are based on information available at the time and may change after claims are processed.
  
  Direct-to-Patient Check Payments
  
  Some plans (including certain Blue Cross/Blue Shield and employer plans) issue payment directly to the member rather than the provider. When your insurer issues payment to you for services provided by Mizuta & Associates Physical Therapy, you agree to remit the insurer payment amount shown on the EOB/ERA within 30 calendar days of the EOB date.
  
  We will provide a copy of the EOB once it becomes available. Your responsibility to remit payment is not contingent upon receipt or deposit of the insurer’s check. If a check is lost, delayed, or sent to an incorrect address, you remain responsible for timely payment and may work directly with your insurer for reissuance.
  
  If you receive any checks or electronic payments related to our services, please notify our office. Once payment has been made to Mizuta PT, you may retain any subsequent insurer payments as reimbursement to yourself.
- Insurance Assignment/Release
- You authorize the release of information necessary to process claims and request that benefits be paid directly to Mizuta & Associates Physical Therapy whenever permitted by your plan. If your plan does not honor assignment and issues payment to you, the Direct-to-Patient Payments policy above applies.
- As Mizuta PT bills my insurance, I understand and that I am responsible for all charges not covered by my plan, including deductibles, coinsurance, and non-covered services.

Payment Options

For patients with a financial obligation - including a deductible to meet and/or coinsurance
To provide a seamless payment experience, invoices include a 3% processing fee for secure online payments.

If you prefer to avoid this fee, you are welcome to pay by check or Zelle. Please email our billing coordinator in advance, and she will adjust your invoice accordingly.
Bill Pay Preferences

HIPAA Privacy & Communication Authorization

Mizuta & Associates Physical Therapy is committed to protecting your health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
By signing below, you acknowledge that you have been offered or have access to our Notice of Privacy Practices, which explains how your medical information may be used and disclosed, and how you can access your information.You authorize Mizuta & Associates Physical Therapy to use and disclose your protected health information for purposes of treatment, payment, and healthcare operations, including coordination of care, billing, and communication with your healthcare providers and insurance carrier, as applicable.

You also consent to be contacted by Mizuta & Associates Physical Therapy via phone call, voicemail, text message, and/or email regarding scheduling, care coordination, billing, invoices, and other matters related to your care. You understand that standard messaging and data rates may apply and that while reasonable safeguards are used, electronic communication may not always be fully secure.

You may request alternative methods of communication or withdraw this consent at any time by notifying our office in writing.

By signing below, you certify that all information provided in this intake form is complete and accurate to the best of your knowledge. You understand that providing incomplete or inaccurate information may impact your care, insurance processing, or financial responsibility.
Signature of patient or responsible party
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Rows	Medication Name	Dosage	Frequency
Medication 1
Medication 2
Medication 3
Medication 4

Intake Form

Medical History

Ericka Mizuta Residential Facility

Cancellation Policy

Billing

Self-Pay Option

Self-Pay Assignment & Release

Medicare Part B Patient Acknowledgement

Insurance Participation

Insurance Assignment/Release

Payment Options

HIPAA Privacy & Communication Authorization