Your assistance in providing the information below is needed to correctly process insurance billing. If there are any questions, please ask. ALL INFORMATION REQUESTED IS NEEDED AND ESSENTIAL!
Date ___________________
Last Name ___________________________First Name ____________________________ MI ___________
SS#____________________ Address___________________________________________________________
HomePhone#___________________Cell Phone#_____________________Work Phone#________________
Referring Physician____________________Primary Care Physician________________________________
Sex: Male/Female Date of Birth________________ Marital Status: Married/Single
E-Mail Address_________________________________
Work Status: Employed /Employed PT/ Full time student
Emergency Contact _____________________________ Phone # ______________________________
Appointment Date/Time__________________________
INSURANCE INFORMATION
(Circle one) Private Workers Comp No-Fault
Company ____________________ Name of Policyholder _________________Birthdate _______________
ID # _______________Billing Address ________________________________________________________
Phone # __________________________________ Contact ________________________________________
Policy#/Carrier Case # ________________________ Group#/WCB File # ___________________________
Type of Injury ____________________________________________________________________________
Date of Original Injury __________ Date of Surgery ___________ Date of Current Injury _____________
Attorney (if any) ______________________________ Phone # _____________________________________
Employer of Insured _______________________________________________________________________
Employer of Patient (if different from above) ___________________________________________________
Address __________________________________________________________________________________
Phone # ________________________________ Supervisor ___________________________
ORANGE PHYSICAL THERAPY

Prescriptions:
To be treated at Orange Physical Therapy, you must have a valid prescription from your physician as well as a referral (if needed) from your insurance provider. It is the patient’s responsibility to ensure that his/her prescription is and remains up-to-date and valid.
Scheduling & Appointments Policy:
We strive to care for our patients with exceptional professionalism and highly personalized service. Our commitment to your well-being and the recovery of your physical abilities is something every member of our staff takes quite seriously. It would be a disservice to you if we did not emphasize the importance of your own commitment to the care you are here to receive.
With this in mind, we request that appointments be made for the full duration of the prescription. After two or more missed appointments you will be discharged from care and your physician and insurance company will be notified of your failure to keep appointments. This may result in denial of payment, making you completely responsible for any outstanding balance on your account.
With the exception of serious emergencies, we expect you to keep all your appointments. Please write down the time of your visits so that you do not forget. If you need to reschedule an appointment we require 24 hours notice. In such a case, please call our office and arrange to reschedule.
All missed or cancelled appointments must be made up within the same week preferably the very next day.
We reserve the right to charge a $50.00 fee for “no shows” and cancellations made without 24 hours notice.
We reserve the right to charge a $75.00 fee for “no shows” and cancellations made without 24 hours notice for Saturdays appointments.
We appreciate your cooperation.
Aaron Loeffler, PT
Orange Physical Therapy
I have read and understand the above policy:
Name:_______________________________________________ Date:_______________________________
ORANGE PHYSICAL THERAPY

PATIENT MEDICAL HISTORY
Patient Name
Date of onset, injury, or surgery
Date
Cause _____________________________
What was your initial treatment?
Have you had other treatment for this condition? Yes ________ No ________ If yes, please explain
Have you had physical therapy for this condition? Yes________ No ________ If yes when/how long________
What are your goals from therapy? _____________________________________________________________
Are you presently out of work due to this injury? Yes________ No ________ As of what date? ___________
Do you now, or have you ever had, any of the following:
Diabetes
Heart Disease
Pacemaker
Kidney Problems
Allergies to Heat
Hernia (Ventral, Inguinal, etc.)
Metal Implants
Cancer _
High or Low Blood Pressure ______
Heart Attack
Migraine Headaches
Nervous Disorders
Allergies to Ice
Seizures
Dizziness
Pregnant (currently)
Fainting
Allergies and/or adverse reactions
______
Hypoglycemia
Any other medical conditions the Physical Therapist should be aware of
Date: Condition:
Condition: Date:
Condition:
Condition:
Date:
Date:
ORANGE PHYSICAL THERAPY

Previous Surgeries, with dates:
Surgery for:
Surgery for:
Surgery for:
Date:
Date:
Date:
Medication List:
I certify to the best of my knowledge, the above information is correct. I understand I am entering into a physical therapy program as prescribed by Dr. of
for treatment in the diagnosis
. My next Doctor visit is scheduled for ___________________________.
I do hereby discharge, release, and hold harmless ORANGE PHYSICAL THERAPY.
and/or any of its personnel from any and all liability for injuries that may be sustained resulting from a condition I may suffer from participation, provided the injury is not the result of intentional negligence on the part of ORANGE PHYSICAL
THERAPY. and/or any of its personnel. I consent to treatment.
I have read, understand, and agree to the above.
Signature Date
ORANGE PHYSICAL THERAPY

ASSIGNMENT OF BENEFITS
I ___________________________ hereby authorize and instruct my insurance carrier to pay Orange
Physical Therapy directly for any physical therapy services performed. Additionally, I understand I am financially responsible for payment of all co-pays, deductibles, and balances not covered by my insurance carrier, provided my specific plan does normally pay for the services and/or products rendered to me by the medical providers at this facility. If I have given incorrect information pertaining to prior Physical
Therapy which results in a denial of payment from my insurance carrier I understand I am financially responsible for payment of all balances. If I am the legal guardian/representative of the patient named above, I accept responsibility for the above as well. I also authorize the release of any and all medical records to my insurance carrier for the purpose of expediting claim payment.
All co-pays, deductibles, and co-insurance amounts are due at the time of service. Any unpaid balance that is the patient or guardian’s responsibility that remains unpaid after 90 days will be sent to collections.
Once the account is sent to collections you will be charged an additional 33.3% of the total amount due, this is the Collection Agency’s fee.
EXPLANATION OF YOUR CO PAYMENT (COPAY)
Definition of “Co-Payment” (also known as co pay ) equals the amount an insured person is expected to pay for medical expense at the time of each visit.
Although this system has been in place for many years, there is a misunderstanding by patients of what their obligations are regarding their co pays.
Co pays are an amount set by the insurance company.
Physical Therapists DO NOT CONTROL OR SET THE COPAY.
Physical Therapists are bound by law (Medicare) and by signed contracts (insurance companies) to collect co pay’s in full at the time of each visit.
FEES are set by the insurance companies and the Federal Government by a complex formula. Each service provider has a set fee. There is no changing of fees by the physical therapists. The physical therapists cannot just bill the insurance companies more to make up for your COPAY responsibility.
Co pays are then subtracted from these fees and the doctor is paid the balance. As an example: If the office visit fee is
$47.00 and the co pay is $40.00, if the doctor does not charge you for the co pay, we would receive $7.00 for the visit as a total fee and therefore would be unable to survive as a business.
Thank you for your understanding.
Signature of Patient or Guardian ________________________________ Date _______________________
ORANGE PHYSICAL THERAPY

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED. IT ALSO DESCRIBES HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY
Effective Date: 05/01/2009
Covered Entity(s): Orange Physical Therapy
Service Delivery Site: 495 Schutt Road Ext. Suite 9 Middletown, NY 10940
An individual’s medical records are considered private and confidential. We at Orange Physical Therapy are committed to serving you with professionalism and caring, being sure at all times to protect the privacy and security of all Protected Health Information.
USE AND DISCLOSURE
During the course of Physical Therapy, it may be necessary to share information with other healthcare providers. Your physician may require Physical Therapy reports. It may be necessary for the therapist to obtain test results that pertain to the condition you are being treated for. Additionally it may be necessary to disclose health information to health insurance(s) or companies to facilitate payment for treatment. It may also be required by attorney(s) to settle a dispute. Disclosure of health information may be further required for administrative purposes and to evaluate the quality of care that you receive by comparing data to improve treatment methods.
Health information may be disclosed without your authorization. Subject to some requirements, we may give out health information for public health purposes, abuse or neglect reporting, auditing purposes, funeral arrangements and organ donation, worker’s compensation purposes, and emergencies. In specific circumstances, information may be required for law enforcement.
INDIVIDUAL RIGHTS
In most cases, you have a right to receive a copy of health information about you that we use to make decisions about your care. You also have a right to receive a list of instances where we disclosed health information about you for reasons other than for treatment, payment, or related administrative purposes. If you believe that information in your records is incorrect or if important information is missing, you have the right to request in writing that we correct the existing information or add the missing information. You have the right to request that your health information be communicated to you in a confidential manner such as sending mail to an address other than your home. You may request in writing that we not use or disclose your information for treatment, payment, or administrative purposes or to persons involved in your care except when specifically authorized by you, when required by law, or in emergency circumstances. We will consider your request but are not legally bound to accept it.
ORANGE PHYSICAL THERAPY

OUR LEGAL DUTY
We at Orange Physical Therapy are committed to obeying all Federal, State, and Local laws and regulations regarding Privacy Practices. Your written authorization to release medical information may be revoked at any time.
If you have any questions or concerns regarding your Protected Health Information, feel free to contact our
Compliance Officer at (845) 342-5170. Please keep this copy for your records.
I acknowledge that I have read and received a copy of the Notice of Privacy Practice.
I consent to disclosure of my health information as described in the Notice of Privacy Practice.
I have been offered the opportunity to request restrictions on certain uses and disclosures of my protected health information.
I understand that I may revoke this consent at any time by notifying the covered entity in writing, except to the extent the covered entity has taken action in reliance on the consent.
__________________________________
Signature of patient or patient representative
________________________ date
ORANGE PHYSICAL THERAPY

Did you

Receive treatment with Orange Physical Therapy in the past

Find us on the internet

Choose us from a list handed to your by your physicians office

Find our brochures/literature in your physicians office

Find us in your insurance provider manual

Find us in the Yellow Pages

Get a recommendation from a family member or friend

Get a recommendation directly from the physician or his staff

Other ______________________________
***Please help us save the trees (and reduce costs too) by supplying your email address.***
We WILL NOT share your email address with anyone, We want to simply keep you up to date with any clinic information we think you should be aware of.
Email: ______________________________________
ORANGE PHYSICAL THERAPY