We want to welcome you to The Orthopedic Group. This packet contains important information needed for
your appointment. Please follow these instructions carefully as you complete each form.
Please arrive 15 minutes prior to your appointment time so that we can review your paperwork.
Forms to complete and return:
__ No Show Policy and letter: signed and dated
__ Patient Information and Benefits form (please complete all patient information and highlighted areas)
Special instructions:
 Auto and Workers Compensation patients: please bring your personal insurance information; we
will need to have this as a secondary on file.
 We will verify benefits at the office (if there is an issue, we will contact you)
__ Health History and Systems Review (please complete)
__ Patient Authorization: initial by each then sign and date at the bottom of the page
__ Workers Compensation: complete Work Related Injuries Form (2 pages)
__ Medicare Primary Insurance: Medicare Therapy Questionnaire and Secondary Insurance Form
Papers for you to keep:
__ Welcome and Instruction Letter
__ Notice of Privacy Practices
To view go to: http://www.theorthopedicgroup.com/index.php/privacy-statement
Or request a hard copy at your appointment
Forms you will complete in the office:
__ Pain Diagram
__ Outcome Measurement Form (will be based on what body part we are treating)
__ Pain description form
__ Informed consent for treatment
Date of 1st visit _____________________Time____________Therapist _____________
Patient Reminders:
Patient financial responsibility – co-pays, co-ins, etc.
Bring script from physician
Bring Insurance Card and Photo ID
Wear or bring appropriate clothing – shorts, sneakers etc.
All completed forms (signed and dated)
If a minor, will need parent/guardian signatures and ID
We thank you for choosing The Orthopedic Group and are looking forward to working with you and helping
you reach your goals.
The Staff at The Orthopedic Group, Physical Therapy
No Show and Cancelation Policy
We strive to provide our patients with excellent service and quality care. Our commitment to your well-being
and health care is something that we at The Orthopedic Group take very seriously.
Your commitment to your physical therapy program is critical to your success. We will recommend treatment
and set goals for you. In order to reach those goals you must do your part and your most important part is to
make each and every appointment.
We will give you an appointment card to keep track for your appointments. If you should misplace this, please
give us a call to review your appointment dates. We expect you to keep all your appointments; however should
you need to cancel please note that we require a 24-hour notice.
If you need to cancel please call our office within 24-hours of your scheduled appointment to reschedule. Our
phone number is _______________.
If you do not show for your scheduled appointment and have not called to cancel, you may be charged $25 for
the missed appointment.
If you miss 3 consecutive appointments we may need to discontinue your treatment.
We thank you for choosing The Orthopedic Group and are looking forward to working with you and helping
you reach your goals.
The Staff at The Orthopedic Group, Physical Therapy
I have read and understand this policy:
_______________________________
Patient/Guardian
____________________________
Date
THE ORTHOPEDIC GROUP
PATIENT REGISTRATION
PERSONAL INFORMATION
FIRST NAME
MI
PRIMARY HEALTH INSURANCE
LAST NAME
INSURED’S NAME (EXAMPLE: SELF, SPOUSE, OR PARENT’S NAME)
ADDRESS
NAME OF INSURANCE COMPANY
CITY
INSURED’S EMPLOYER
STATE
ZIP CODE
(
WORK PHONE NUMBER
(
HOME PHONE NUMBER
)
ID NUMBER
GROUP NUMBER
CELL PHONE NUMBER
)
(
)
COPAY AMOUNT
INSURED’S BIRTHDATE
E-MAIL ADDRESS
RELATIONSHIP TO PATIENT:
DATE OF BIRTH
AGE
SEX – M or F
 SINGLE
 SPOUSE
 PARENT
 OTHER
SECONDARY HEALTH INSURANCE
SOCIAL SECURITY NUMBER
MARITAL STATUS
 SELF
INSURED’S NAME
 MARRIED
 DIVORCED
EMPLOYER
 WIDOWED
NAME OF INSURANCE COMPANY
PATIENT’S EMPLOYER
OCCUPATION
ID NUMBER
STATUS:
 FULL TIME
 PART TIME
BEST TIME TO REACH YOU:
GROUP NUMBER
COPAY AMOUNT
INSURED’S BIRTHDATE
MAY WE CONTACT YOU AT WORK:
RELATIONSHIP TO PATIENT:
STUDENT STATUS:
 FULL TIME
 SELF
 PART TIME
SCHOOL NAME
OCCUPATION
(
PHONE NUMBER
)
YOU WERE REFERRED BY:
YOUR FAMILY DOCTORS’ NAME IS:
(
PHONE NUMBER
)
EMERGENCY CONTACT:
NAME
(
RELATIONSHIP
)
 OTHER
PLEASE READ, SIGN, AND DATE:
SPOUSE’S SOCIAL SECURITY NUMBER
HOME PHONE NUMBER
 PARENT
Name of parent/guardian if patient is a
minor______________________________
SPOUSE’S NAME
SPOUSE’S EMPLOYER
 SPOUSE
WORK NUMBER
(
)
I request that payment of authorized
Medicare/other insurance benefits be made
on my behalf to THE ORTHOPEDIC GROUP for
any services furnished me by physician or
supplier. I authorize the release of my
medical information to the Centers for
Medicare & Medicaid Services and/or my
insurance company and its agents; any
information needed to determine these
benefits/benefits payable for related services.
I am responsible for all charges, regardless of
insurance status, as well as co-payments and
deductibles.
SIGNATURE: ____________________________
DATE: ___________________
HISTORY AND SYSTEMS REVIEW
Patient Name: __________________ ________________ ____
(First)
Date of Birth: ________
(Last)
Age: _____
(MI)
Nickname/Name Preference: ____________
Male or Female
Height: ____ Weight: _____
Marital Status: __ Single
__Married __Widowed __Other
Occupation: ___________________________________________________
Leisure Activities: _______________________________________________
Describe the reason for your visit: ______________________________________________________________
Date of Injury: ______________
When was the onset of your problem ________________________________
What is the length of time your symptoms have been present? ____________
Onset: (Check One) Gradual ___ Sudden ___
How did the problem occur? _______________________________________
Contact or Non-Contact
Did you hear any NOISE associated with the onset of the injury? __________
Where was the pain initially felt? ___________________________________ Now, where is it? ___________
Did you have SWELLING immediately? ______________________________
Type of Pain (Circle)
Dull
Sore
Constant
Intermittent
Sharp
Throbbing
Bruised
Burning
Have you had any previous or similar problems? ____________________________________________________
Are you CURRENTLY seeing any of the following:
Reason (If seen in past 3 months- illness, medical condition, physical exam, etc):
Medical Doctor:
Yes/No
________________________________________________________________________
Osteopath:
Yes/No
_______________________________________________________________________
Dentist:
Yes/No
___________________________________________________________________________
Psychiatrist/Psychologist: Yes/No ____________________________________________________________________________
Physical Therapist:
Yes/No ____________________________________________________________________________
Chiropractor:
Yes/No ____________________________________________________________________________
Date of last complete physical exam: Month _________________ Year___________ Physician __________________
Please list any surgeries or other conditions for which you have been hospitalized:
Approx. Date
Surgery / Hospitalization / Reason
____________
________________________________________________
____________
________________________________________________
____________
________________________________________________
Please describe any injuries for which you have been treated:
Approx. Date
Injury (fractures, dislocations, sprains, strains)
____________
________________________________________________
____________
________________________________________________
____________
________________________________________________
Which of the following OVER-THE-COUNTER medications have you taken in the last week: (Circle)
Aspirin
Antacids
Tylenol
Vitamins/Mineral Supplements
Antihistamines
Advil/Motrin/Ibuprofen
Laxatives
Decongestants
Other ____________________
Please list any PRESCRIPTION medication that you are currently taking (including pills, injections, or skin patch)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
(Continued on page 2)
HISTORY AND SYSTEMS REVIEW (page 2)
Please list any ALLERGIES you may have (if you have no allergies, list NONE)
___________________________________________________________________________________________
___________________________________________________________________________________________
Could you be or are you pregnant? _____________________
How much caffeinated coffee or other caffeine containing beverages do you drink per day? _______________
How many packs of cigarettes do you smoke per day? _______________________________
How many days per week do you drink alcohol? ____________________________________
During the past month have you often been bothered by feeling down, depressed, or hopeless? ____________
Have you or any of your family EVER been diagnosed as having any of the following: (circle all that apply)
Cancer:
SELF FAMILY MEMBER:
Cancer (Type:Heart Problems )
SELF FAMILY MEMBER:
Asthma
SELF FAMILY MEMBER:
High Blood Pressure SELF FAMILY MEMBER:
Emphysema/COPD
SELF FAMILY MEMBER:
Depression
SELF FAMILY MEMBER:
Hepatitis
SELF FAMILY MEMBER:
Stroke
SELF FAMILY MEMBER:
Anemia
SELF FAMILY MEMBER:
Multiple Sclerosis
SELF FAMILY MEMBER:
Tuberculosis
SELF FAMILY MEMBER:
Diabetes
SELF FAMILY MEMBER:
Chemical Dependency
SELF FAMILY MEMBER:
Kidney Disease
SELF FAMILY MEMBER:
Osteoporosis
SELF FAMILY MEMBER:
Thyroid Problems
SELF FAMILY MEMBER:
Rheumatoid Arthritis
SELF FAMILY MEMBER:
Epilepsy
SELF FAMILY MEMBER:
Other Arthritic Conditions SELF FAMILY MEMBER:
SELF FAMILY MEMBER:
Have You Had, Or Do You Experience:
Cardiovascular System
YES
NO
Elevated cholesterol
Sweating associated with pain
Palpitations
Swelling of extremities
History of smoking
Orthopnea (difficulty breathing)
___
___
___
___
___
___
___
___
___
___
___
___
GI System
YES
NO
Pulmonary System
YES
NO
Dyspnea (labored breathing)
Wheezing
Prolonged cough
___
___
___
___
___
___
Difficulty swallowing
Heartburn
Jaundice (yellow appearance)
Specific food intolerance
Constipation
Diarrhea
Rectal bleeding
Gall bladder problems
Liver problems
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
G.U. System
YES
NO
Dysuria (painful urination)
Hematuria (blood in urine)
Incontinence
Urinary urgency
Painful Menstration
Frequency in urination
___
___
___
___
___
___
___
___
___
___
___
___
Neurological System
YES
NO
Endocrine System
YES
NO
Poor Muscular Coordination
Memory lapses
Confusion
Head Trauma
Neurological Disorder
Tremors
Slurred speech patterns
Hearing/Visual disturbances
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
Excessive thirst
Excessive hunger
Fatigue
Weakness
Thyroid problems
___
___
___
___
___
___
___
___
___
___
Other Systems
YES
NO
ENT (ears, nose, throat)
Lymphatic
Psychiatric
Musculoskeletal
___
___
___
___
___
___
___
___
The information listed is correct to the best of my knowledge.
Patient/Guardian Signature: _________________________________________________
Date: __________
Patient Authorization
Patient Name: _________________________
Date of Birth: __________
Release of Information & Consent for Treatment
All information provided herein is true and correct.
I am aware of my diagnosis and wish to receive treatment at The Orthopedic Group. I permit its employees and all other
persons caring for me to treat me in ways they judge are beneficial to me. I consent to rehabilitation and related services
at this Facility. I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily
contact, touching and/or direct contact of a sensitive nature. I understand that this care can include an evaluation, testing,
and treatment. No guarantees have been made to me about the outcome of this care.
I give permission to The Orthopedic Group to release information, verbal and written, contained in my medical record, and
other related information, to my insurance company, rehab nurse, case manager, attorney, employer, school, related
healthcare provider, assignees and/or beneficiaries and all other related persons as it relates to my treatment and/or
payment for services provided. I authorize The Orthopedic Group to obtain medical records and/or professional
information from my physician or other medical professional as it relates to my treatment. The signature below certifies
that I have read and understand the above information.
Initial: ____
Assignment of Benefits
I authorize payment directly to The Orthopedic Group, its subsidiaries and/or affiliates for services and to bill and release
payment directly to The Orthopedic Group, its subsidiaries and/or affiliates for any physical therapy, rehabilitation, orthotic
or prosthetic services provided. This is a direct assignment of my rights and benefits under this policy. A photocopy of this
assignment shall be considered as effective and valid as the original.
Initial: ____
Notice of Privacy Practices (HIPAA Acknowledgement/Consent)
I hereby acknowledge that I have received a copy of The Notice of Privacy Practices for The Orthopedic Group. In
addition, I hereby consent to the use and disclosure of my personal health information for the purposes of treatment,
payment, and health care operations.
Initial _____
Payment Guarantee
I agree to pay The Orthopedic Group, its subsidiaries and/or affiliates for the services provided to me or the party named
above. If any law, such as workers’ compensation, or insurance contract prohibits payment for these services I will
cooperate and assist in the provision of information, authorizations, releases, or any other type of information necessary
to allow for speedy collection from my third-party payer. Where the law or an insurance contract does not prohibit payment
by me, I acknowledge responsibility for any and all account balances.
The Intake & Verification of Benefits Form is only an explanation of coverage obtained from my insurance company and
it is not a guarantee of coverage. If the information provided by my insurance company is not accurate or the insurance
company changes its coverage, I will be responsible for payment for services. I understand that my good-faith payment
may not be inclusive of all payments for which I am responsible and I may be billed for any remaining balance.
I further understand that this agreement is binding regardless of any legal transaction currently in progress or initiated
during or after the course of my treatments unless agreed to in writing by myself and a representative of The Orthopedic
Group.
Initial _______
Patient Information & Data Sheet
I hereby acknowledge that the information I provided on the Intake Form and all Patient Information is correct.
Initial: ______
Patient or Guardian Signature: _____________________________________ Date: ________________
Witness Signature: _______________________________________________ Date: ________________