439 Mechem
Ruidoso, NM 88345
(575) 257-1800
Fax 257 -2319
MC-PATIENT INFORMATION
Name:
Nickname:___________________
Mailing Address:
State:
City: ________________
ZIP:
-
Phones Home: (
Physical Address:________________________________
)
-
Business:(
)
M □ F□
Social Security:
Email:
Cell:(
Birth Date:
Weight:
)
-
Marital Status:_________________
@
Height:
-
Age:______
Occupation
Does your position consist mainly of: Sitting?
Standing?
How did you hear of us? Dr.
Newspaper
Friend
Radio
Walking?
Sign
Lifting?
Other
Please give us their name so we may thank them:______________________________________
List any significant: diseases / conditions / allergies / surgeries / including specific cardiac / pulmonary
_________________________________________________________________________________
Do you have any infectious diseases? Y N If yes please list:______________________________
Prior to this injury, how many days a week did you exercise?
Have you been treated for this
condition before? Y N When?:___________________________
Do you have trouble getting to sleep? Y N Does your pain wake you up? Y N If Yes how many
times a night?
How many times do you get up in the night to use the bathroom? _________
Do you smoke? Y N Quit
Do you have a pacemaker? Y N
Have you fallen in the last 12 months? Y N
Females: Are you pregnant? Y N
How many times?
Injury Y N
Please indicate pain level with a P for Present a B for Best and a W for Worst on the line below:
No pain:
0
1
2
3
4
5
6
7
8
9
10
Worst pain
MC-PATIENT INFORMATION
Page 2
Emergency Contact Information:
Name:________________________
Relationship to Patient:__________
Phone # (
Cell # (
)_________________
) ___________________
Patient signature:___________________________________ Date______________
Work related injury? Y N / Auto Accident? Y N
WORKMANS COMPENSATION / AUTO ACCIDENT INFO:
Date and place of injury:_________________________________________________
Claim#
Contact person
Phone#:___________
PHYSICAL THERAPY MEDICARE PATIENTS
Please answer the following questions so that we can better serve you regarding your
Medicare billing.
1. Have you received Physical Therapy, Speech Therapy or Chiropractic Care since
January 1, 2013?
❑YES
❑NO
If YES, at what facility did you receive the therapy or care?
2. Have you had any Home Health Therapy in the past year? ❑YES
If YES, were you discharged? Please include discharge date.
❑YES discharged on
❑NO
Agency Name
❑NO
Phone#
After your deductible has been paid, Medicare pays 80% of the allowable charges for
Physical Therapy and you are responsible for 20% unless you have a supplemental
insurance that will cover these charges.
Medicare does not pay for everything, even some care that you or your Healthcare
Provider have good reason to think you need. Medicare will only pay for 5 units of timed
services per visit, with a maximum of 60 units of timed service per month. If you feel you
need more units, you may request them and pay for the additional units.
The Ruidoso Physical Therapy Clinic, Inc. would like you to be aware of the 2013
Medicare Cap of $1,900.00. The Cap applies to combined Outpatient Physical Therapy,
Speech Therapy, Chiropractic Care. If you exceed the CAP, you are responsible for the
charges incurred.
To qualify for an EXCEPTION to the MEDICARE CAP, the beneficiary must be making
measurable progress towards achieving functional and medically necessary goals. We
cannot guarantee medicare payment. For further information, please ask your therapist.
I understand and agree to pay all charges that exceed the $1900.00 Medicare Cap not
paid by Medicare to The Ruidoso Physical Therapy Clinic, Inc.
Patient’s signature:__________________________________ Date: ___________
We encourage you to call or write to your congressman to repeal the Medicare
Cap.
Our mission is to get you back to a pain-free, active lifestyle.
THE RUIDOSO PHYSICAL THERAPY CLINIC
We would like to welcome you to THE RUIDOSO PHYSICAL THERAPY CLINIC. We
are happy to bill your primary insurance company after you supply us with all necessary
information.
MEDICARE INFORMATION: Medicare coverage is 80%, the 20% balance is covered under
your supplemental insurance, which is automatically filed at the time your Medicare claim is
filed. If you have no supplemental insurance, please pay your 20% share at each visit. If your
supplemental insurance does not respond, you will be billed for this.
TREATMENT CONSENT: I request and authorize the staff of The Ruidoso Physical Therapy
Clinic to provide me with treatment, and to perform any procedures now contemplated or such
additional procedures as my doctor may deem reasonable and necessary.
CANCELLATION POLICY: We require notification in the event you need to cancel any
scheduled appointment with The Ruidoso Physical Therapy Clinic, 4 hours PRIOR to
appointment time. Our office staff or answering service is available 24 hours a day. IF YOU
FAIL TO NOTIFY THIS OFFICE OF YOUR CANCELLATION, A $35.00 FEE WILL BE
ASSESSED. Your insurance company cannot be billed for cancellations; therefore, you will be
required to pay this fee on your next visit. Your insurance company and your physician will be
notified of your cancellation._______ (Please initial.)
RELEASE OF INFORMATION: I authorize the release of my medical records to my insurance
company. I AUTHORIZE MY INSURANCE COMPANY TO MAKE INSURANCE PAYMENT
DIRECTLY TO THE RUIDOSO PHYSICAL THERAPY CLINIC.
FINANCIAL RESPONSIBILITY:
CO-PAYS AND DEDUCTIBLES ARE DUE AT THE TIME OF TREATMENT. You will be
responsible for all remaining charges after your insurance has paid its share unless we are
contracted with the company. It may take several months for insurance payment, at which time
you will be billed for the remainder of the account balance. Please be aware that after 1
unsuccessful attempt to collect balance you will be charged a late fee of 2% of the overdue
balance each month it is overdue. After 2 unsuccessful attempts, your account will be
considered delinquent. After 3 unsuccessful attempts, the account will be turned over for
collection and assessed a collection fee of $25.00 plus costs incurred for collection.
I UNDERSTAND I AM LEGALLY OBLIGATED TO PAY FOR PHYSICAL THERAPY
TREATMENTS AT THE TIME OF SERVICE UNLESS I AM COVERED BY MEDICARE, AN
HMO, WORKERS COMPENSATION, OR OTHER INSURANCE.
Patient’s signature:________________________________ Date: ______________
The following signature authorizes treatment and also the release of information stated
above if the patient is a minor.
Parent/Guardian: _________________________________ Date:_______________
The Ruidoso Physical Therapy Clinic, Inc.
439 Mechem Drive ~ Ruidoso, NM 88345-6813
(575) 257-1800
FAX 257-2319
Acknowledgment of Receipt of Notice of Privacy
Practices
Patient Name (PLEASE PRINT):____________________________________________
Patient Phone:________________________________________________________
Patient Address:_______________________________________________________
Signing this document signifies that you have received a
copy of our Notice of Privacy Practices.
In the course of providing service to you, we create, receive
and store health information that identifies you. It is often
necessary to use and disclose this health information in
order to treat you, to obtain payment of our services, and to
conduct healthcare operations involving our office. The
Notice of Privacy Practices you have been given describes
these uses and disclosures in detail.
I acknowledge that I have received the Notice of Privacy Practices from
The Ruidoso Physical Therapy Clinic, Inc.
Signature
Date
If signing as a personal representative of the patient, describe the relationship to the
patient and the source of authority to sign this form:
Relationship to Patient
Print name
Source of Authority:______________________________________________________