Intake Form - Quality Physical Therapy

Patient Info and Medical History Form

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Patient's Legal name

First

Last

to Single

Gender

Male
Female

Address

City

State

ZIP CODE

Name of the person referring

Phone Number

Date of Birth

Last 4 digits of SSN

Notification

Email
Phone- Call
Phone Text

May we speak to your spouse about your medical Condition

Not Married
Yes
No

Spouse Name

Spouse Number

Who else may we speak to concerning your medical condition?

Phone Number

Employer

Occupation

Address

City/ZIP/State

Diagnosis

Referring Physician's Name

Physician Address

Physician / Office Phone Number

Single Line Text

If injury is due to accident, DATE OF INJURY

MM/DD/YYYY

CLAIM ID

Adjustor Handling claim

Adjustor Phone

Insurance Company Name

Insured Name:

Relationship to Patient

Members ID #

Group #

Phone Number

PATIENT MEDICAL INFORMATION

Name
AGE

Patient Name

Patient Age

Patient Height

Patient Weight

Referring Physician

Primary Care Physician

Problems to be Treated

Have you had treatment for this problem before?

If YES, state where and when

If any conditions checked above, please explain and give approximate dates. Describe any other conditions.

FALL HISTORY

Injury as a result of fall in past year?
Two or more falls in the last year?
Patient at risk for falls?
N/A

SURGICAL HISTORY 1

Surgical History1

1.Body Region

1.Surgery Type

1.DATE

SURGICAL HISTORY 2

Surgical History2

2.Body Region

2.Surgery Type

2.DATE

Currently taking Medication ?

LIST OF MEDICATIONS TO BE SCANNED IF TAKING MORE THAN 4

DRUG 1

1.Drug Name

1.Dosage

1.Frequency

1.Route

1.Reason Taking

LIST OF MEDICATIONS TO BE SCANNED IF TAKING MORE THAN 4

DRUG 2

2.Drug Name

2.Dosage

2.Frequency

2.Route

2.Reason Taking

LIST OF MEDICATIONS TO BE SCANNED IF TAKING MORE THAN 4

DRUG 3

3.Drug Name

3.Dosage

3.Frequency

3.Route

3.Reason Taking

LIST OF MEDICATIONS TO BE SCANNED IF TAKING MORE THAN 4

DRUG 4

4.Drug Name

4.Dosage

4.Frequency

4.Route

4.Reason Taking

Authorization for Treatment

I hereby authorize and consent to rehabilitation services provided by Quality Physical Therapy & Rehabilitation, P.C, including any procedures which may be performed during this visit for Patient mentioned above.

Assignment of Insurance Benefits and Release of Information

I hereby assign and authorize direct payment to Quality Physical Therapy and Rehabilitation, P.C. of all insurance benefits payable to me under the terms of any insurance policy for the services rendered, but not to exceed the regular charge for services received. I authorize any holder of medical information about me or any information needed to determine benefits payable for related services to be released to my insurance carrier, third party payor, and managed care organization or to any other insurance carrier, including worker's compensation claims. I authorize a copy of the authorization to be used in place of the original.

Medical Patient Certification

I certify that the information given by me in applying for payment under Title XVIII or Title XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I permit a copy of the authorization to be used in place of the original and request payment of authorized benefits to be made on my behalf.

Medicaid Authorization and Assignment

I request that payment of authorized Medicaid, Medigap or other Medical Assistance programs be made on my behalf to the above provider for services furnished to me by the provider/supplier. I authorize any holder of medical information about me or any information needed to determine benefits payable to be released to my insurance carrier. My signature certifies that I have received a service beginning with the date below. I understand that payment for this service will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of material may be prosecuted under applicable Federal and State Law.

Personal Valuables/Dependents/Visitors

It is understood and agreed that Quality Physical Therapy and Rehabilitation , P.C. is not responsible for loss or damage to any personal valuables or properties. In order to maximize safety, small children will not be allowed in the treatment area of the clinic. If older children are present, please keep them off the exercise equipment in order to prevent injuries. There may be exceptions, please ask if you have any concerns or questions. We will do everything possible to accommodate your schedule if you are a caretaker of small children.

Financial Agreement, Guarantee of Account

I, the undersigned agree whether I sign as parent, guardian, spouse, agent, guarantor or as patient, that in consideration of the services to be rendered to the patient, I hereby individually obligate myself to pay the account of Quality Physical Therapy and Rehabilitation, P.C. in accordance with the regular rates and terms of the Facility. I understand that therapy services are rendered and charged to the patient and not to the insurance company, and the facility cannot accept total responsibility for collection of claims nor for egotiating a disputed settlement. I agree to be responsible for al deductibles, coinsurance and noncovered portions of service erformed. I understand that Quality Physical Therapy and Rehabilitation , P.C. is not a party to any lawsuit I may have due to litigation. I furthe understand that although information will be provided to my attorney, I am fully responsible to the provider for payment in full under the regular terms of the practice. Should the account be referred to an agency or attorney for collection, I shall pay actual attorney's fees, 35% collection expense, and 24% annual interest rate. There is a $25 charge for cancellation without proper notice. This charge will not be covered by insurance and will have to be paid by me personally.

Notice of Privacy Practices

Our Notice of Privacy Practices provides information about how we may use and disclose medical information about you. As indicated in our notice, the terms of our notice may change. If we change our notice, you may request a revised copy. By signing below, you are stating that you have reviewed the Notice of Privacy Practices. Our Notice of Privacy Practices is posted in the waiting area, but you may request a written copy of the Notice at any time. You may also ask any questions about the Notice at any time.

Signature

Type Full Name