Patient Intake

Spero Rehab - Katy

Patient Intake Forms
Full Name *

First Name Middle Name Last Name
Sex
Date of Birth *

- Month - Day Year

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number
State Issued ID #: *
if child, please use parent's ID.
Social Security Number *
This is required to accurately verify your insurance benefits
E-mail *
Ordering Doctor *
Name, Phone Number, Fax Number
INSURANCE INFORMATION
Insurance Company *
Primary Subscriber's Name - if different than patient
If not the patient, please include full name and relationship to patient
Primary Subscriber's Date of Birth
Insurance Phone Number *
Member ID *
Group Number
Claims Mailing Address on Card
**Only fill out your Secondary Insurance information if you have Medicare as a primary. We do not bill secondary insurances unless you have Medicare as a primary.
Seconday Insurance Company
Insurance Phone Number
Member ID
Group Number
Claims Mailing Address on Card
AUTHORIZATION FOR RELEASE OF INFORMATION

Spero Rehab will only disclose the protected health information (PHI) you want disclosed.
Please acknowledge by checking each box. *

I auhorize that the payment of my insurance benefits be made directly to Spero Rehab for all services delivered; if I am paid directly, I will promptly pay Spero Rehab all monies paid to me. I further authorize the release of any medical or other information pertinent to my case to any insurance company, adjuster, or attorney involved in the case for the purposes of processing claims and securing payment of benefits. I understand that all payments designated as "the patient's responsibility" such as co-insurances and deductibles are due and payable at the time of service or statement receipt. I guarantee I will pay the amount deemed "my responsibility" by my insurer by the statement ude date. I certify that the information I have provided Spero Rehab for payment including, but not limited to related accidents, illnesses or other insurers is accurate and truthful.
Check only ONE box to tell Spero Rehab the specific information you want disclosed/released. *

Do not release any information unless required by law or related to treatment or payment. ALL records regarding my care at Spero Rehab to any requesting party. Limited information.
Complete only if you selected "limited information". I only authorize the release information to the individuals/entities identified by name:
Please acknowledge by checking each box. *

I understand that this authorization does not expire as long as Spero Rehab has custody of my files. I understand that I can refuse to give authorization without fear of retaliation or treatment limitations. I understand that if I give authorization, I may revoke it at any time by notifying Spero Rehab in writing. I understand that the information used/disclosed as a result of my authorization may be subject to re-disclosure by the recipient and may not be protected by Federal privacy regulations once in the recipient's possession. I understand that if Spero Rehab requests my authorization, they are required to tell me the purpose and to whom my PHI is being released to. I understand that I can receive a copy of this authorization upon request. Spero Rehab will not be compensated for using or disclosing my PHI unless related to treatment or payment procedures unless specific permission is obtained after full disclosure of purpose and intent.
Credit Card On File:

If you would like to leave your Credit Card on file, please fill in the blanks below. You also have the option to add your card on file in the office. If you do not wish to do this, you may bypass this section.
Type of Card:
Name on the Card:
Credit Card Number:
Expiration Date:
Security Code
Billing Address:
Spero Rehab Pre Exam Questionnaire
What is your age? *
What is your height and Weight? *
Have you had physical therapy before? *
Please describe your problem (what caused it? Is this a single injury or a chronic injury?) *
When did it start? *

- Month - Day Year
Have you had this pain or problem before? *
How much have your symptoms interfered with your usual daily activities? (including work outside the home and housework) *
What functional activities are you limited with? Please check all that apply. *

Self-Care Mobility: walking and moving around Changing and maintaining body position Carrying, moving and handling objects
Where is your pain? *
On a scale from 1-10 (10 being the worst) What is your current pain? *
What is you pain at its worst in the past 2 weeks? (scale from 1-10) *
What is your pain at its best in the past 2 weeks? (on a scale from 1-10) *
What are your goals for therapy. PLEASE BE SPECIFIC. *
Pleas list ALL CURRENT MEDICATIONS: *
Please list ALL past surgeries with dates: *
Please list ALL MEDICAL CONDITIONS: *
Spero Rehab Policies

Thank you for choosing Spero Rehabilitation, LLC as your rehabilitation provider. We are committed to providing our patients with the best available medical care. Our billing department will be available to discuss our fees and policies with you if you have an questions. We ask that all responsible parties read and initial our financial and office policies prior to being seen by a therapist.
Please acknowledge by checking each box. *

NO SHOWS AND CANCELLATIONS: If you fail to show for an appointment without a phone call to cancel, you will be assessed a $40 fee to your account. We require a 24 hour advance notice if you want to cancel or change your appointment.This fee is not covered by your insurance. LATENESS: Being more than 15 minutes late may require you to reschedule, however, a $30 fee will be charged and partial services may still be offered at the discretion of the therapist. COPAYS, COINSURANCE & DEDUCTIBLES: All copays, deductibles, and/or coinsurances are due at the time of service. We do not choose these fees. They are provided to our office by your insurance company when we call to verify benefits and/or the terms agreed upon by you (or your employer) and the insruance company. It is unlawful to avoid paying your copay, coinsurance or deductible. Under Federal Standards, you may NOT routinely evade paying your responsibility portions for medical care as outlined in your insurance plan even if your doctor allows it. PERSONAL CHECKS: Any personal check returned for insufficient funds will be charged a fee of $35 in addition to the amount of the check. After one instance of a returned check, all further payments will be required to be in the form of a credit card or cash. REQUEST FOR MEDICAL/BILLING RECORDS: There is a $25 fee per case (example: PT case, OT case, SLP case) per request for copies of medical and/or billing records. PCP REFERRALS: Some insurance companies require an authorization for your Primary Care Physician (PCP) in order to receive physical therapy services. Please note that this is different from an order for physical therapy. This is authorization that your PCP must get from your insurance provider. Our office must have this in hand at the time ot your first appointment. YOUR RESPONSIBILITY: We verify insurance benefits as a courtesy to our patients. All charges are your responsibility whether your insurance company pays or does not pay. Not all services are a covered benefit in your medical plan. Some insurance companies select certain services they will not cover. Please contact your insurance company if you have questions as to what is covered. You are ultimately responsible for all charges that are not covered under your health care policy. NOTE: Your insurance is a contract between you (or your employer) and the insurance company. We are not a party to the contract. It is very important that you understand the provisions of your healthcare policy. We cannot guarantee payment of all claims. If your insurance company pays only a portion of a bill or rejects your claim, any contract or explanation should be made to you, the policy holder. Reduction or rejection of any claim by your insurance company does not relieve you of your financial obligation. In the event that your insurance company pays us for a claim that you had already paid and you are due a refund, we will be happy to expedite your refund or credit your account. VISIT LIMITATIONS: It is your responsibiltity to keep track of the number of visits that your insurance company covers per year. Going over the limit will cause claims to be denied and will ultimately be your financial responsibility at time of service.
Patient Signature *
By typing your name above, you acknowledge that all information provided is up to date and correct.
Today's Date *
To complete your intake process, please use your phone and take a picture of both your drivers license, as well as, the front and back of your insurance card. Then you can either upload them to this website or email them to us at contact@sperorehab.com All of this can be done very easily from your phone and save you time once you arrive at our facility. You can also upload from your computer. This is not required - but we do recommend it. Thank you!
Driver's License
Front of Insurance Card
Back of Insurance Card
Doctor's Order
Should be Empty:

Spero Rehab - Katy

INSURANCE INFORMATION

AUTHORIZATION FOR RELEASE OF INFORMATION

Credit Card On File:

Spero Rehab Pre Exam Questionnaire

Spero Rehab Policies