Fullerton Physical Therapy and Sports Care, Inc.
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- Felicia Jennings
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1 Fullerton Physical Therapy and Sports Care, Inc. Patient Information: Title Address Patient Name (Last, First, Middle initial) City/State/Zip Home Phone Work Phone Cell Phone Social Security DOB Gender Driver s License M F Address Referring Physician Marital Status Occupation Address Employer City/State/Zip Emergency Contract (Name) Home Phone Work Phone Have you had any other physical therapy or chiro services this year? Y N If so, how many visits? Have you had any home health care this year Y N Financially Responsib Party if Not Patient Name (Last, First, Middle initial) Address Relationship to Patient City/State/Zip Home Phone Work Phone Social Security DOB Sex M Inquiry Information Address F Driver s license Is condition surgery related? Is condition accident related? Describe Accident Date of surgery Was an automobile involved? Surgical Procedure Date of Accident Where you injured on the job? Date of Injury Name of employer at the time of accident? City/State/Zip Code Describe Injury Litigation Involved? Name of Attorney Phone
2 MEDICAL INFORMATION QUESTIONNAIRE IN ORDER TO EVALUATE YOUR CONDITION FULLY, THE FOLLOWING PATIENT HISTORY IS ESSENTIAL. PLEASE BE AS ACCURATE AS POSSIBLE. NAME (please Print) DATE PATIENT ILLNESS OR INJURY: FOR WHAT CONDITION OR SYMPTOM ARE WE SEEING YOU? WHEN DID THIS PROBLEM BEGIN? (Date) WHAT TREATMENT HAVE YOU ALREADY RECEIVED? HAVE YOU EVER HAD THIS PROBLEM IN THE PAST? PAST MEDICAL HISTORY: (PLEASE INDICATE IF YOU HAVE HAD ANY OF THE FOLLOWING CONDITIONS) ARE YOU PREGNANT DO YOU HAVE A PACEMAKER OSTEOPOROSIS FAMILY HISTORY: HAS ANY IMMEDIATE (BLOOD) RELATIVE HAD ANY OF THE FOLLOWING: (CIRCLE) ARTHRITIS DIABETS BLEEDING TENDENCY HEART DISEASE CANCER STROKE HEART DISEASE: ANGINA ANGIOPLASTY. ARRHYTMIA. ATHEROSCLEROTIC DISEASE (CAD). CONGESTIVE HEART FAILURE (CHF). CORONARY ARTERY BYPASS GRAFT (CABG). HEART ATTACK (Myocardial Infarction)-(MI).. HIGH BLOOD PRESSURE. STENTS... VALVULAR DISEASE... LUNG DISEASE ASTHMA..... EMPHYSEMA COPD....
3 VASCULAR DISEASE: ACQUIRED RESPIRATORY... BLEEDING or BLOOD DISORDERS CHRONIC BRONCHITIS DIABETES... DISTRESS SYMDROME (ARDS)... PERIPHERAL ARTERIAL DISEASE... STROKE/TIA... TAKING BLOOD PRESSURE MEDS... GENERAL MEDICAL CONDITIONS: ALLERGIES... ANXIETY OR PANIC DISORDER... ARTHRITIS (rheumatoid/osteoarthritis)... BACK PAIN (neck pain, lower back, degenerative disc disease, spinal stenosis)... CANCER/TUMOR... DEPRESSION... EPILEPSY or CONVULSIONS... GASTROINTESTINAL DISEASE (ulcer, hernia, reflux, bowel, liver, gall, bladder)... HEADACHES... HEARING IMPAIRMENT... HEPATITIS... HERNIAS... INCONTINANCE... PREVIOUS ACCIDENTS... KIDNEY, BLADDER, PROSTATE OR URINATIN PROBLEMS... NEUROLOGICAL DISEASE (such as MS or Parkinson s)... PRIOR SURGERY (S)... PHOSTHESIS/ SURGICAL IMPLANTS... SLEEP DYSFUNCTION... VISUAL IMPAIRMENT (such as cataracts, glaucoma, macular degeneration)... IF CHECKED, PLEASE DESCRIBE OTHER MEDICAL PROBLEM T LISTED? ALLERGIES: (CIRCLE) IODINE COMPOUNDS TAPE HEAT OIL COLD TALCUM POWDER OTHER: MEDICATIONS YOU RE CURRENTLY USING:
4 Important Info for All Medicare Patients Regarding Home Health Dear Medicare Patient, Please be advised that Medicare will not cover outpatient physical therapy if you are currently receiving home health care. Home Health Care means services provided by a licensed home health agency to an insured in his/her place of residence that is prescribed by the insured s attending physician as part of a written part of care. This can include ANY medical treatment that you receive in your home, such as nursing care, speech therapy, or chemotherapy, not just physical therapy. If you have received any home health services, it is imperative that the home health agency formally discharges you before you begin physical therapy in our office. Even if your home health care treatment has ended, Medicare will not cover physical therapy unless they have an official home care discharge date on file. Please contact your home health agency if you have received care at home in the recent past to ensure you have been completely discharged. If you have any questions, please stop by the billing department. We are here to provide the highest quality of patient care and are happy to help address any concerns you may have. I have read and understand the above information regarding Medicare s policy for home health care and outpatient physical therapy. Yes, I have had home health care. My last date of treatment at home was / /. I have or will contact my home health agency to make certain I was properly discharged. No, I have not had home health care. Patient Name: Patient Signature: Date: / /
5 TICE OF PRIVACY PRACTICES INFORMATION ABOUT YO MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 1. OUR PLEDGE REGARDING MEDICAL INFORMATION The privacy of our information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information. 2. OUR LEGAL DUTY Law Requires Us to: 1. Keep your medical information private. 2. Give you this notice describing our legal duties, privacy practices and your rights regarding your medical information. 3. Follow the terms of the current notice. We Have the Right to: 1. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law. 2. Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created and received before the changes. Notice of Change to Privacy Practices: 1. Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request. 3. USE ANFD DISCLOSURE OF YOUR MEDICAL INFORMATION The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose
6 not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice. FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care you. We may also share medical information about you to your health care providers to assist them in treating you. FOR PAYMENT: We may use and disclose your medical information for payment purpose. A bill may be sent to or third-party payer. The information on or accompanying the bill may include your medical information. PRIVACY PRACTICES ACKWLEDGEMENT ACKWLEDGEMENT FORM Name Birth Date Signature Date Please Print Out This Form Set And Sign And Date Pages 5 and 7.
Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address
Patient Information Patient Information Date of Birth Sex Marital Status Male Female Single Married Other Social Security Number - - Why We Ask for Race and Ethnicity Patient Goes By: Email Address In
Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION. Cell Phone ( ) Employer s Name
Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION Name Last First M.I. Social Security. Home Address Street City State Zip Mailing Address
Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #:
5002 Highway 39 N Bldg. A Meridian, MS 39301 Phone: 601-512-0500 Fax: 601-512-0505 Patient Information Patient: Gender: Male Female First Middle Last Primary Language: English Spanish Other Mailing Address:
DRUG / MEDICATION ALLERGIES: (include: Type/Reaction)
NASSAU CHEST PHYSICIANS PC MEDICAL QUESTIONNAIRE 1 DATE: PATIENT NAME: DOB: DRUG / MEDICATION ALLERGIES: (include: Type/Reaction) 9/1/2014 PHARMACY NAME PHARMACY PHONE PHARMACY Street Address City State
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351 Osborne Road, Loudonville, New York ARWynnykiwDDS. Welcome!
351 Osborne Road, Loudonville, New York 12211 518.432.3991 518.432.3987 smile@albanydds.com ARWynnykiwDDS www.albanydds.com Welcome! When it comes to dentists, I know that you have many options. My goal
LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W
PATIENT REGISTRATION LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W D OTHER: SPOUSE S NAME: EMAIL ADDRESS:
Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name
*SHAREDID-42* Date of Birth: Page 1 of 2 Patient Registration Account # Patient Name Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex City, State & Zip Code
Print Guardian Name (If not patient) DOB: Patients Name: (Last, First, MI): Circle One: - - / / Mailing Address: Apt. #: City: State: Zip Code:
Patients Name: (Last, First, MI): SSN: DOB: Circle One: Male Mailing Address: Apt. #: City: State: Zip Code: Female Race: Ethnicity Primary Language: Home Phone: Preferred? Cell Phone: Preferred? Employer:
Office Hours Our office hours are Monday through Friday 7:30 am to 5:30pm. Our office is closed on all major Holidays.
Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints
New Patient Registration Form NJR_NP_F100
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PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!
PATIENT INFORMATION FORM PATIENT DATA: - - PATIENT NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY # SEX ( ) - ( ) - ADDRESS HOME PHONE NUMBER MOBILE PHONE NUMBER CITY STATE ZIP CODE OCCUPATION / / DATE OF
GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP
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R. B. KO L A C H A L A M M. D. GENERAL SURGERY
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MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE
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NORTH COUNTY PHYSICAL THERAPY, INC. DBA MISSION PHYSICAL THERAPY GROUP
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PATIENT REGISTRATION FORM Please Print
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PATIENT WILL NOT BE SEEN WITHOUT PHOTO ID Patient Information Kimberly Walpert, M.D. 1199 Prince Avenue Athens GA 30606 Ph 706-475-1870 Fax 706-475-1879 www.athensbrainandspine.com Patient Name First Middle
Tel: Fax:
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ACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION CONSENT TO USE OR DISCLOSE MEDICAL INFORMATION
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Page 1 of 5 1/4/17. Print Guardian Name (If not patient) DOB: Circle One: - - Patients Name: (Last, First, MI):
Patients Name: (Last, First, MI): SSN: DOB: Circle One: Male Mailing Address: Apt. #: City: State: Zip Code: Female Race: Ethnicity Primary Language: Home Phone: Preferred? Cell Phone: Preferred? Employer:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
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(Please Print) PATIENT INFORMATION. Sex: Male Female Home phone no: ( ) City: State: Zip: Cell phone no: ( ) Occupation: Employer: Work phone no: ( )
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Dear New Patient, Once again, we would like to thank you for choosing us as your primary health care provider. We look forward to working with you.
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Dear Patient, Sincerely, Gastroenterology Associates of North Jersey
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