LPTSR PATIENT INTAKE FORM

I, _{name}__, understand that as part of my health care, Lincoln Physical Therapyand Sports Rehab, LLC originates and maintains paper and/or electronic records describing my health history, symptoms, examinationand test results, diagnoses, treatment and any plans for future care of treatment. I understand that this information serves as;

A basis for planning my care and treatment.
A means of communication among the many health professionals who contribute to my care.
A source of information for applying my diagnosis and surgical information to my bill.
A means by which a third-party payer can verify that services billed were actually provided.
A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of informationuses and disclosures.Lincoln Physical Therapy and Sports Rehab, LLC will comply with your request unless the information is needed to provide youemergency treatment. To request restrictions you must make your request in writing in the space below. I understand that I may revokethis consent in writing, except to the extent that the organization has already taken action in reliance upon this consent. I alsounderstand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted bySection 164.506 of the Code of Federal Regulations. I further understand that Lincoln Physical Therapy and Sports Rehab, LLCreserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code ofFederal Regulations. Should they change their notice, they will send a copy of any revised notice to the address I’ve provided

I wish to have the following restrictions to the use or disclosure of my health information:

Due to HIPAA rules, if you would like your spouse, family member, or friend to have access to your account or health information, you will need to list their names and connection to you below:

I understand that as part of this organization’s treatment, payment, or health care operation, it may become necessary to disclose myprotected health information to another entity. I consent to such disclosure for these permitted uses, including disclosure via fax

I fully understand and accept the terms of this consent:*

AgreeDiagree

Patient Signature*

Patient Intake Form

Have you received any of the following treatments during your current plan year?

If insured is other than patient:

Primary Complaint