Partners in Therapy & Wellness New Patient Acknowledgements

New Patient Acknowledgements
Consent to Treatment

I recognize that I am suffering from a condition requiring physical therapy services and treatment. I hereby consent to the rendering of physical therapy services by Partners in Therapy, as described to me or as my physician or Partners in Therapy determines necessary. I understand that the practice of physical therapy is not an exact science and no guarantees have been made to me about the outcome of treatment. I voluntarily request the right to participate in Partners in Therapy physical therapy and/or wellness program. I do hereby discharge, release, and hold harmless Partners in Therapy and any of its personnel participating in this rehabilitation program from any and all liability for damage of any kind.
Initial*
Consent of Disclosure (HIPPA release)

I hereby give consent to Partners in Therapy to use and disclose my protected health information for the purposes of treatment, payment, and health care operations. You may cancel this consent at any time. Your cancellation must be in writing, signed by you or on your behalf, and delivered in person or by mail, but will only be effective when actually received. Your cancellation will not be effective to the extent that others we have acted in reliance upon this consent. You have the right to request restriction on the usage and disclosure of your protected health information for the purposes of treatment, payment, or health care operations.
Initial*
Financial Responsibility

I hereby give consent to Partners in Therapy to use and disclose my protected health information for the purposes of treatment, payment, and health care operations. You may cancel this consent at any time. Your cancellation must be in writing, signed by you or on your behalf, and delivered in person or by mail, but will only be effective when actually received. Your cancellation will not be effective to the extent that others we have acted in reliance upon this consent. You have the right to request restriction on the usage and disclosure of your protected health information for the purposes of treatment, payment, or health care operations.
Initial*
The undersigned patient or Responsible Party acknowledges that he/she has read and agrees to the information printed above.
Signature*
Printed Name*
Date*

MonthDayYear
Date

Patient Information
Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MaleFemale
SSN*
DOB*
Home Number
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
E-mail*
How did you hear about us?*
Emergency Contact Name*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Referring Physician
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Injury/Illness Information
Diagnosis
Date of Injury

MonthDayYear
Date
Date of Surgery

MonthDayYear
Date
Primary Insurance Information
Insurance Company Name
Phone Number
Format: (000) 000-0000.
Subscribers Name
Subscribers DOB
Relationship
ID #
Group #
Employee Phone
Format: (000) 000-0000.
Secondary Insurance Information
Insurance Company Name
Phone Number
Format: (000) 000-0000.
Subscribers Name
Subscribers DOB
Relationship
ID #
Group #
Employee Phone
Format: (000) 000-0000.

New Patient Acknowledgements

Patient Information

Injury/Illness Information

Primary Insurance Information

Secondary Insurance Information

Medical History