Welcome to Rebound Sports & Physical Therapy!
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1 Welcome to Rebound Sports & Physical Therapy! We are happy you chose us to assist with your care. We strive towards providing an excellent experience for all our patients as we assist you in regaining your active lifestyle. Here is an outline of some things to expect during your visits to our clinic: Initial Visit Your physical therapy / occupational therapy evaluation: Your physical therapist/occupational therapist will take a thorough medical history as well as take appropriate measurements and perform physical therapy/occupational diagnostic tests as part of the examination. Your therapist will provide you with helpful information regarding your condition and outline a treatment plan so you know what to expect during future appointments. Please bring comfortable clothing that is easy to move around in to this appointment. An initial examination lasts approximately 60 minutes. Follow-up visits and treatment: At Rebound, you will always work with the same physical therapist/occupational therapist that performed your initial evaluation unless you agree to or want a different therapist. We want what is best for you! All of our physical therapists/occupational therapists are licensed by the state of Colorado and are trained in the latest methods in biomechanics, functional recovery, and pain relief. Follow-up visits usually last around 30 minutes, but may extend up to 45 minutes depending on your situation. Arriving for your appointments: Please check in with our front desk staff. They are ready to assist you with any scheduling questions you may have. Once they check you in, your physical therapist/occupational therapist is alerted that you are in the clinic. If you expect to be late for your appointment, kindly call our office as we may have to reschedule you. Checking out from your appointments: Please stop and check out with our front desk staff. They will collect any payment for service per your insurance plan (see financial information below.) They will also go over your future scheduled appointments with you to assure that your calendar and our calendar match. Financial Information: Payment for service is expected at each visit. Insurance plans differ greatly, but most plans have a copayment, co-insurance, or deductible amount that needs to be paid when physical therapy or occupational therapy services are rendered. Ultimately, it is your responsibility to understand your coverage and we encourage you to contact your insurance company s customer service department with any questions you have. We offer self-pay rates if not going through insurance. Please ask our front desk staff for more information if you have questions. If you anticipate difficulty in paying, please call our billing department so they can come up with an agreeable payment plan for you. Medicare Patients: If you have Medicare, there are some additional guidelines that apply to you for Medicare to cover physical therapy/occupational therapy services. These are as follows: Medicare requires you to be under the care of a physician. Your doctor will receive a plan of care after the initial evaluation which must be approved. Periodically a new plan of care will be forwarded to your physician by your therapist should you need further rehabilitation services. Medicare does not cover outpatient physical therapy/occupational therapy in conjunction with homecare services. Once again, thank you for choosing Rebound Sports & Physical Therapy for your rehabilitation needs. We look forward to meeting you!
2 PATIENT SUMMARY : PERSONAL INFORMATION Legal First Middle Initial Last Preferred Home Phone Cell Phone Work Phone Appointment Reminders Text Voice If text or voice, which number? Spouse Minor - Parent(s) (s) Emergency Contact Emergency Contact to Patient MEDICAL HISTORY Referring Physician of Injury Primary Care Physician of Surgery of next physician visit Please check the appropriate response. NO Do you smoke? Do you exercise regularly? Is your current condition work accident related? If yes, date of injury? Is your current condition auto accident related? If yes, date of injury? Have you had physical, occupational, speech, massage or chiropractic care for any reason this year? Please check if you have ever (in your life) had, or do you presently have any of the following: 1 Anemia / Blood Disease 2 Bone / Joint Problem 9 Diabetes 10 Dizziness / Fainting 17 High Blood Pressure or High Cholesterol 18 Lung Disease 3 Arthritis / Rheumatism 4 Allergies 5 Back Trouble 6 Breathing Problems (any kind) 7 Broken Bones / Dislocation / 8 Sprains Cancer or Tumor 11 Epilepsy / Seizure Disorder 12 Fibromyalgia Syndrome 13 Headaches 14 Head / Spinal Injury 15 Heart Disease / Chest 16 Hernia / Rupture 19 Paralysis 20 Pregnancy (Current) 21 Skin Disease or Sores That Won t Heal 22 Stroke 23 Swelling of Feet or Joints 24 Other Page 1 of 4 ON BACK
3 MEDICAL HISTORY CONTINUED Please provide details of any recent/relevant surgeries below: Surgery / Procedure CURRENT SYMPTOMS 1. Describe your symptoms a. When did your symptoms start? b. How did your symptoms begin? c. What activities produce your symptoms/make them worse? 2. What describes the nature of your symptoms? Sharp Shooting Dull Ache Burning Numb Tingling 3. How are your symptoms changing? Getting Better Not Changing Getting Worse 4. During the past 4 weeks: NONE WORST a. Indicate the worst intensity of your symptoms: b. At best, what is the intensity of your symptoms: Who have you seen for your symptoms? No One Medical Doctor Chiropractor Physical Therapist Other 6. What is your occupation? MEDICATIONS/ALLERGIES If you are currently taking any medications please list below: Medication Are you allergic to any medications? / NO if, what? Any other known allergies? / NO if, what? Page 2 of 4
4 CONSENT TO TREAT / PRIVACY PRACTICES / HIPAA Patient (please print) CONSENT TO TREAT I certify that I have reviewed and understand the information supplied by me and that it is true and correct to the best of my knowledge. I hereby consent to such treatment, procedures, patient care, and therapy supplies which, in the judgment of my therapist and/or physician, may be considered necessary or advisable while a patient at Rebound Sports & Physical Therapy. PRIVACY PRACTICES I, the below named patient, understand that I am entitled to certain privacy rights regarding protected health information according to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I also understand that this information can and will be used to convey treatment plan, insurance payments, and administrative activities. I understand and have been given the opportunity to receive a copy of the entire Notice of Privacy Practices prior to signing this consent and understand that I may revoke this authorization in writing, except to the extent that action has already been taken. HIPAA I, the below named patient, understand that there may be occasions where I wish to have my protected health information be released to other individuals. This includes, but is not limited to any other health care providers (other than your referring physician), family members, coaches, trainers, etc. I give permission for Rebound to release my protected health information to the persons listed below: I have had the opportunity to review, read and request a copy of Rebound Sports & Physical Therapy s HIPAA Notice of Privacy Practices. In addition to, and in compliance with HIPAA regulations, I give my permission for my protected health information to be disclosed for purposes of communicating results, findings, care decisions and appointments, and for claims resolution. Page 3 of 4
5 PATIENT FINANCIAL RESPONSIBILITY AGREEMENT ATTENDANCE POLICY, AUTHORIZATION TO RELEASE INFORMATION, & ASSIGNMENT AGREEMENT PATIENT ATTENDANCE POLICY I, the below named patient, understand that Rebound is fully committed to helping me to reach my rehabilitation and injury prevention goals. I understand that I will receive a printed list of all scheduled appointments and can be provided appointment reminders via , text, or phone call if desired. I have read the attendance policy outlined below and understand that I play a key role in successfully reaching my goals with regular attendance to my appointments and completing my treatment plan as prescribed by my therapist. If you are going to be late for your appointment, please notify the clinic as soon as possible so they can alert your therapist. Please know that if you are going to be more than minutes late, your appointment may be rescheduled for another date/time. We kindly request 24-hour notice for any appointment you need to cancel to ensure we can help get you rescheduled timely. Please call our front desk at (970) to cancel. In the event that you cancel 3 or more consecutive appointments without notice, your case will be discharged and a new case would have to be opened for you to return to therapy. If you miss an appointment and fail to provide notice (no-show), you will be charged $25. This charge will be directly billed to you and is not covered by any insurance or payor. In the event that you fail to provide notice (no-show) for 2 or more consecutive appointments, your case will discharged and a new case will have to be opened for you to return to therapy. RELEASE OF INFORMATION I, the below named patient, hereby authorize Rebound Sports & Physical Therapy to release to any third party payor (such as an insurance company or governmental agency) any medical condition and records concerning diagnosis and treatment when requested by such third party for its use in connection with processing a claim for payment for such treatment and/or diagnosis. INSURANCE ASSIGNMENT I, the below named patient, hereby authorize direct assignment of my authorized medical insurance benefits and request that payment of these benefits be made on my behalf directly to Rebound Sports & Physical Therapy for any professional services rendered. I understand and agree that the professional services include care provided by physical therapists, occupational therapists, exercise specialists, athletic trainers, interns in training, and massage therapists working under the direction and supervision of the treating therapist(s). A copy of this authorization will be sent to the Health Care Financing Administration, my insurance company, or other entity if requested. The original authorization will be kept on file by Rebound Sports & Physical Therapy. MY RESPONSIBILITY I, the below named patient, understand it is my responsibility to pay at the time of service any deductible amount, co-payment, co-insurance, supplies or any other balance not paid for by my insurance. All major credit/debit cards, checks, and cash are accepted. If you anticipate difficulty in paying, please call our office to discuss a payment plan with one of our billing specialists. If minors will be attending their appointments alone, please make advanced arrangements for payment of services with the billing department. Please note: Insurance policies have many different plans covering physical therapy/occupational therapy services. We will assist you in any way we can, but ultimately it is your responsibility to understand your coverage. If you are unsure of the coverage of your specific plan, we encourage you to contact your insurance company s customer service department. If this account is assigned to an attorney for collection and/or suit, the prevailing party shall be entitled to reasonable attorney's fees and costs of collection. I PERMIT A COPY OF THESE AUTHORIZATIONS AND ASSIGNMENTS TO BE USED IN PLACE OF THE ORIGINAL, WHICH IS ON FILE AT REBOUND SPORTS & PHYSICAL THERAPY. This assignment will remain in effect until revoked by me in writing. Patient (please print) Page 4 of 4
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Patient Information (Please Print) Dr. Miss Mr. Mrs. Sir Patient s Name (Last) (First) (MI) Previous Name Address Line 1 City, State ZIP Home Phone Cell No. Work Phone Ext. Primary Care Provider (PCP)
Emergency Contact Name: Relationship: Home #: ( ) Cell #: ( ) Alternate #: ( ) Pharmacy Information Pharmacy Name: Phone #: ( ) Location:
New Patient Office Information Last Name: First Name: Initial Date of Birth: SSN # Marital Status: Single Married Divorced Widowed Address: City: State: Zip: Gender: M Parent/ Legal Guardian if Patient
History Form. PAST SURGICAL HISTORY Surgeries/Hospitalizations Year Complications/Problems with anesthesia
History Form Name: Date of Birth: Today's Date: Height: Weight: Date of Injury: Primary Care Physician: Address Who recommended this office? Address CHIEF COMPLAINT Why are you seeing the doctor today?
Middle Initial: Street Address: City: Date of Birth: Age: Marital Status: Occupation: Employer: Name of Spouse: Emergency Contact:
SALT LAKE EYE ASSOCIATES, LLC (801) 281-2020 1025 E 3300 S, SLC, Utah * Patient Information Sheet First Name: Last Name: Middle Initial: Referred By Family Doctor EMAIL Street Address: City: State: Zip:
Patient Health Questionnaire - PHQ ACN Group, Inc. - Form PHQ-202 ACN Group, Inc. Use Only rev 7/18/05
Patient Health Questionnaire - PHQ ACN Group, Inc. - Form PHQ-202 ACN Group, Inc. Use Only rev 7/18/05 Patient Name 1. Describe your symptoms a. When did your symptoms start? b. How did your symptoms begin?
PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Patient Name: Date of Birth: SSN: Cell Number: Cell Phone Provider: Home Number: Work Number: Home Address: City/State: Zip: Employer: Occupation: E-Mail: Relationship Status: S M W
Patient Intake Form. Address City State and Zip
Patient Intake Form Patient Information First Name Last Name Sex: Male Female Birthday Address City State and Zip May we send you text reminders of future appointments? Yes / No Email Phone Number If yes,
Neck & Spine Patient Demographic
Neck & Spine Patient Demographic o New Patient o Return Patient o Update Account #: Physician: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg.
Pediatric Patient History
Pediatric Patient History Childs Name: Today s Date: Primary Doctor: Date of Birth: Age: Reason for visit: List all chronic medical problems: List all medication dosages and frequency taken (including
Welcome to Hawaii Women s Healthcare
Cheryl Lynn T. Rudy, M.D. Cheryl L. Leialoha, M.D. Erin C. Gertz, M.D. Laura A. Spector, D.O. Andrea Wieland, APRN Welcome to Hawaii Women s Healthcare Hawaii Women s Healthcare strives to provide you
Anne C. Roulo, DC 7501 Murdoch Ave, Shrewsbury, MO, Patient Data Sheet
Anne C. Roulo, DC 7501 Murdoch Ave, Shrewsbury, MO, 63119 314.484.0690 Patient Data Sheet Date Name: Address: City: State: Zip: Social Security Number: - - Email: Home Phone: ( ) Cell Ph.: ( ) Work Ph.:
YOUTH ACTIVITIES REGISTRATION FORM
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POTS Treatment Center 7515 Greenville Avenue, Suite 1005 Dallas, TX
Patient Registration: POTS Treatment Center 7515 Greenville Avenue, Suite 1005 Dallas, TX 75231 214-369-8717 Date: Briefly state the medical problem for which you made this appointment today : Name : Address:
PEDIATRIC CENTER FOR WELLNESS, P.C. CRYSTAL B. HOOD, M.D KLONDIKE RD SW SUITE 205 CONYERS, GA TELEPHONE FAX
PEDIATRIC CENTER FOR WELLNESS, P.C. CRYSTAL B. HOOD, M.D. 1506 KLONDIKE RD SW SUITE 205 CONYERS, GA 30094 678-750-4000 TELEPHONE 678-750-4005 FAX www.pcfwellness.com Dear Family, We are excited to welcome
MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Patient Name: Date: Date of Birth: SSN: Male Female Guarantor Name: SSN: DOB: Home Phone: Cell Phone: Street Address: Apt#: City: State: Zip: Billing Address (if different): Email
*Family Chiropractic Care* New Patient Information Worksheet*
*Family Chiropractic Care* New Patient Information Worksheet* Name: SSN: Age: Address: City: State: Zip: Phone Hm: Wk: Date of Birth: E-Mail Employer: Insurance: Policy/I.D. # : Spouses Name: Marital Status:
Adult History Form. Patient Name Today s Date Birth Date Sex Weight Height Name You Go By Please Check Married Single
Adult History Form It is a pleasure to welcome you to our family of happy and healthy chiropractic patients. Please let us know if there is any way we can make you and your family feel more comfortable.
Rosati Family Chiropractic Intake Form
Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name I prefer to be called by Address City State Zip Code Home Phone ( ) - Work Phone ( ) - Cell Phone (
Workers Compensation Demographic
Workers Compensation Demographic Account #: Physician: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg. Cell Phone o OK to Leave Msg. Email Do
I acknowledge I have read and understand this office s Notice of Privacy Practices. (A copy can be furnished to you at your request)
Patient s name: Email Address: Do you wish to receive emails with special offers/newsletters? Yes No I acknowledge I have read and understand this office s Notice of Privacy Practices. (A copy can be furnished
Dodge. County. Schools
Welcome to the Dodge School Based Health Clinic. Dodge Board of Education and Dodge Connection-Communities In of Dodge, Inc. are continuing to move forward with our goal of serving the children and families
Norman H. Anderson M.D., P.A. Robert Boissoneault Oncology Institute INSURANCE AUTHORIZATION
Norman H. Anderson M.D., P.A. D/B/A Robert Boissoneault Oncology Institute 2020 SE 17 th Street Ocala, Fl 34471 522 N. Lecanto Highway Lecanto, FL 34461 605 W. Highland Blvd. Inverness, FL 34452 9401 SW
City. Whom may we thank for referring you to us?
CAMBRIDGE DENTAL CENTER - PATIENT REGISTRATION Date Patient's Last Name First :Kame MI Age Soc. Sec. No.: Home Work Phone: Home rujul
Lake Mary Eye Care Adult Form
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Welcome to University Family Healthcare, PA.
Welcome to University Family Healthcare, PA. We re delighted that you have chosen us as your primary care providers. We work hard to earn your trust and to see that you have the best healthcare possible.