Initial Call Date ________________
Previous Patient:
□ No □ Yes, When ________________
Patient Information
Legal First Name: _______________________________________
Middle Initial: _________________
Last Name: _____________________________________________
Name you wish to be called or Nickname _____________________
In the case of a minor, what are the parents’ names:
Mother ___________________ Father ____________________
□ Male
Gender:
Date of Birth: ___________________________________________
□ Not a Student □ FT Student □ Part Time Student
Student:
Marital Status:
Work Status:
Where does this minor reside?
□ Mother □ Father □ Both □ Other ______________________
□ Female
□ Married □ Single □ Other
□ Employed □ Retired
□ Unemployed
□ Not Working Due to Injury □ Student
Occupation: ____________________________________________
Address Information
Home
Address:
Employer: ___________________________________________
Address:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
City: ______________________ State _____ Zip _________
City: ______________________ State _____ Zip _________
Patient Contact Information
Which number would you prefer us to contact you:
□ Cell □ Home □ Work □ Alternate/Emergency
Due to HIPAA laws, we are required to ask you whether we
may/may not leave a voice message on your recorder
Cell Phone: _____________________________________
□ OK to leave message with detailed information
□ Call back information only
□ DO NOT LEAVE MESSAGE
Home Phone: _____________________________________
□ OK to leave message with detailed information
□ Call back information only
□ DO NOT LEAVE MESSAGE
Work Phone: _____________________________________
□ OK to leave message with detailed information
□ Call back information only
□ DO NOT LEAVE MESSAGE
Alternate/Emergency Contact
Who should we contact in case of an emergency:
Name:
_______________________________________________
Relationship: ___________________________________________
Phone: _________________________________________________
□ OK to leave message with detailed information
□ Call back information only
□ DO NOT LEAVE MESSAGE
Would you like to receive email reminders of your appointments?
□ Yes □ No
Would you like to receive paperless billing?
□ Yes □ No
Would you like to receive Rehab1Network’s e-newsletter? It
contains beneficial information on proper posture, exercises, and
tips for healthy living!
□ Yes □ No
Email: ________________________________________________
Revised 7/1/2016
Patient’s Name: _________________________________________________
DOB: _________________
Injury Information
Body Part Injured
______________________________________________
Date of Onset: ________________________________ Did you have surgery?
Referring Physician _______________________________________
□ Left □ Right □ Bilateral
□ No
□ Yes
□ Not Applicable
Date of Surgery: ________________
Primary Care Physician ___________________________________
How did this injury occur?
□ Fall □ Sports □ Employment □
Auto Accident
□ None of the above
If Auto Accident or Employment Injury, in which State did the accident occur? _________________ and
Date of Accident? ____________________________
Do you have an appointment to return to your referring physician? □ No
□ Yes, Date: __________________
Have you received ANY previous physical, speech or occupational therapy since January 1st of this year from ANY provider
(hospital, nursing home, home health, other outpatient facility)?
□ No □ Yes
If yes, from whom: ________________________________________________________________
How many visits did you have: _______________; When was your last visit: ___________________
Release of Medical Information - HIPAA
Rehab1Network’s HIPAA Policies regarding the safekeeping of my personal and medical information have been made available to me and I
understand this information will only be shared with my referring physician, insurance provider and/or employer in the case of a workers
compensation claim.
I further, hereby consent to release information regarding my treatment and/or billing to the following:
____________________________________
Print Person’s Name
_________________________
Relationship
____________________________________
Print Person’s Name
_________________________
Relationship
Consent to Treat and Insurance Release Information
I hereby consent to the medical care and treatment procedures as determined necessary by my physician(s) and/or therapist(s). I further authorize
Rehab1Network to release to my insurance company any necessary information needed to file and expedite payment on my claim. I hereby irrevocably
assign and transfer to Rehab1Network any and all benefits, either contractual, common law, or statutory, to which I am entitled or which are available to me
under any medical, health, and accident, or workers’ compensation policy, plan, or program. I hereby authorize and direct that any such payments be paid
directly to Rehab1Network. I further authorize and agree that a copy of this authorization shall be deemed valid as the original. In the event that I would fail
to pay my bill, I agree to pay any additional charges related to the cost of collection (including, but not limited to, collection agency fees, reasonable attorney
fees and court costs). In the case of a returned check, there will be an additional $35.00 charge.
In consideration of our other patients, I agree, if possible, I will contact this facility in advance if I need to cancel or arrive late for an appointment. I
understand if I fail to show for an appointment without notification or cancel an appointment without a 24-hour notice, I may be subjected to the $35.00
Late/Cancelled Appointment charge. If I miss two (2) or more consecutive appointments without notification, all future appointments may also be cancelled.
I further understand if circumstances result in my late arrival for a scheduled appointment, I may be asked to re-schedule. Missed and/or Cancelled
Appointment charges are my responsibility and will not be billed to my insurance provider.
Further, we are a teaching site for student physical/occupational therapists. Students working under the direct supervision of our physical/occupational
therapist may assist in your care. If you wish that a student not be involved in your care, please let your physical/occupational therapist know as soon as
possible
I acknowledge the information on this form to be accurate.
X_______________________________________________________
Patient/Parent/Legal Guardian Signature
_________________
Date
Revised 7/1/2016