CLINIC NAME: Sunnyvale Physical Therapy
RX DATE:
PATIENT INFORMATION
SCHD APPT:
TX START DATE :
THERAPIST:
NAME:
SOCIAL SECURITY #
ADDRESS:
CITY:
HOME PHONE: (
)
-
MOBILE: (
DATE OF BIRTH:
)
-
STATE:
WORK PHONE: (
)
-
MARITAL STATUS: Single
ZIP:
EXT:
PATIENT SEX: Male
PERSON TO CONTACT IN CASE OF EMERGENCY:
RELATIONSHIP:
PHONE: (
REFERRING PHYSICIAN:
)
PHONE: (
DATE OF INJURY OR SURGERY:
)
-
DIAGNOSIS:
CAUSE OF COMPLAINT DUE TO:
AUTO
WORK
ICD #
OTHER:
NAME OF INSURED/ POLICY HOLDER
NAME:
RELATIONSHIP TO PATIENT:
SOCIAL SECURITY #
EMPLOYER NAME:
PHONE: (
)
-
Do you have a secondary insurance?
INSURANCE INFORMATION
PRIMARY
NAME OF INSURANCE COMPANY:
Yes
No
BILLING ADDRESS:
PHONE: (
)
-
REPRESENTATIVE:
POLICY/ ID#
BENEFITS:
GROUP#
%
REQUIRES PRE –AUTH:
DEDUCTIBLE:
YES
NO
AUTHORIZED BY:
SECONDARY
NAME OF INSURANCE COMPANY:
EFFECTIVE DATE:
MET: NO
COPAY $
AUTH #
OUT OF POCKET MAX:
# OF VISITS AUTHORIZED:
DATE:
PLAN LIMITATIONS:
PHONE # (
)
-
)
-
INSURANCE BILLING ADDRESS:
POLICY HOLDER:
RELATIONSHIP TO PATIENT:
SOCIAL SECURITY/ MEMBER ID#
GROUP#
WORKERS’ COMPENSATION / AUTO INFORMATION
NAME OF INSURANCE COMPANY:
PHONE # (
ADDRESS TO SUBMIT CLAIMS:
ADJUSTER:
DATE OF INJURY:
PHONE # (
)
-
CLAIM #
AUTO POLICY #
)
-
PREVIOUS PT/OT (This Injury)
EMPLOYER:
AUTO PATIENTS ONLY :
FAX # (
PHONE # (
POLICY HOLDER:
)
YES
NO
-
RELATIONSHIP:
MED-PAY ON POLICY:
YES
NO
MEDICARE PATIENTS ONLY
DO YOU HAVE MEDICARE PART A & PART B?
ARE YOU ENROLLED IN MEDICARE PART D? (Prescription Drug Plan)
HAVE YOU RECEIVED HOME HEALTH WITHIN THE LAST 2 MONTHS?
ARE YOU CURRENTLY RECEIVING ANY TYPE OF THERAPY AT ANOTHER FACILITY OR HOSPITAL?
HAVE YOU PREVIOUSLY RECEIVED PT/OT FOR THIS DIAGNOSIS?
TRICARE/TRIWEST PATIENTS ONLY
ARE YOU CURRENTLY AN ACTIVE MEMBER IN THE SERVICE?
AMOUNT $
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
YES
NO
Insurance Benefits and Payment Policy: The information listed above is a description of your healthcare benefits, which was given to us by a representative of your health
insurance company. It is not a guarantee or authorization of payment. Actual benefits cannot be determined until the claim has been received and processed by your insurance.
We will call to verify your insurance coverage. Deductibles and co-payments are due at the time of service.
I hereby give lifetime authorization for payment or insurance benefits to be made directly to this healthcare provider for services rendered. I understand that I am financially
responsible for all charges not paid by my insurance company. In the event of default, I agree to pay all costs of collection and reasonable attorneys fees. I further agree that a
photocopy of this agreement is as valid as the original. I further authorize that my signature on this form constitutes assignment of benefits to the above name healthcare
provider.
I consent to have this healthcare provider and/or its’ affiliates provide the treatment and care prescribed by my physician(s). I understand this consent may be revoked by me at
any time.
___________________________________________________
____________________________________
PATIENT’S SIGNATURE
DATE
PAYMENT POLICY
Payment is due at the time of service. We will accept cash, personal check, Visa and Master Card. If you
are covered by medical insurance, we accept your co-payment amount for each visit at the time of service. As a
courtesy, PRN will bill your insurance carrier for services rendered. You are responsible for all co-payments, your
deductible and any amounts determined by your insurance plan, as not deemed medically necessary. Patients
should remember that services rendered by our company are rendered to the patient, and not to the insurance
carrier. The patient is responsible for payment of all charges that your insurance does not cover.
CONSENT FOR TREATMENT
I consent to have Sunnyvale Physical Therapy and/or its affiliates to provide the treatment and care
prescribed by my physician(s). I understand this consent may be revoked by me at any time.
ASSIGNMENT OF MEDICAL BENEFITS
I hereby authorize payment of medical benefits to Physical Rehabilitation Network (PRN) for medical
services rendered.
AUTHORIZATION TO RELEASE MEDICAL RECORDS
I hereby authorize the release of any medical records and information, including statements of my account
pertinent to this injury or illness, which are necessary to process this claim.
APPOINTMENT CANCELLATION POLICY
If you are unable to keep your appointment please RESCHEDULE or CANCEL your appointment at least
24 hours in advance. If you should have (3) appointment cancellations with inadequate notice, or (2) “no shows”
for scheduled appointments we will cancel any remaining appointments, notify your physician, and discharge you
as a patient. We have 24 hour answering machines for your convenience during non-working hours, weekends,
and holidays.
______________________________________
Patient Signature
__________________________________________
Date
Effective March 1, 2003
PATIENT PRIVACY NOTICE
THIS ABBREVIATED NOTICE BRIEFLY DESCRIBES HOW HEALTH INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment: We may use health information about you to provide you with healthcare treatment or services. We may disclose health
information about you to personnel who are involved in taking care of you.
For Payment: We may use and disclose health information about you so that the services you receive from us may be billed to insurance
carriers and payment collected.
For Healthcare Operations: We may use and disclose health information about you for operations that are necessary to run related
services.
Health-Related Services and Treatment Alternatives: We may use and disclose health information to tell you about health-related
services.
Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your
health and safety or the health and safety of the public or another person.
Military and Veterans: If you are a member of the armed forces or separated/discharged form the military services, we may release
health information about you as required by military command authorities or the Department of Veteran Affairs.
Workers Compensation: We may disclose health information to a health oversight agency as authorized by law.
Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may disclose health information about you in response to a court
or administrative order etc…
Law enforcement: We may release health information if asked to do so by a law enforcement official.
YOUR RIGHTS READING HEALTH INFORMATION ABOUT YOU
Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your
care.
Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the
information.
Right to an Accounting of Disclosures: You have the right to request a list accounting for any disclosures of your health information we
have made, except for uses and disclosures for treatment, payment, and healthcare operations, as previously described.
Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose
about you for treatment, payment, or healthcare operations.
Right to Request Confidential Communications: You have the right to request that we communicate with you about health matters in a
certain way or at a certain location.
Right to a paper Copy of This Notice: You have the right to obtain a paper copy of the entire PHI Privacy notice at any time.
We reserve the right to change this notice at any time. We will post a copy of the current notice in our facility.
If you would like a complete copy of the Protected Health Information Privacy Notice, please ask the Patient Coordinator.
_____________________________________________________
Patient Signature
_________________________ ____
Date
Physical Rehabilitation Network (PRN)
Sunnyvale Physical Therapy
Name:
Date:
Please place an X in the areas that are affected:
When did your symptoms begin? Less than 1 week
1-3 months
3 or more months
How did it occur?
Work
Surgery
Are you off work due to this injury?
Are your symptoms:
Yes
Getting better
Less than 1 month
Other
Unsure
No
Other
If yes, since when?
Getting worse
About the same
What is your main complaint and what areas of your body are involved?
Have you ever had or do you now have any of the following? (“X” all that apply)
Asthma
Head trauma/convulsions
Diabetes
Allergies
Kidney disease
Stroke
Hernias
Vascular disease
Pregnancy
Cancer
High blood pressure
Dizziness
Heart disease
Blood disease/HIV
Seizures
Sleeping difficulties
Change in body weight
Alcoholism
Metal implants
Balance problems
Respiratory illness
Rheumatic disease
Have you had surgery for the injury?
Yes
If yes, what was the date you had surgery?
Have you had a similar injury/occurrence before?
If yes, please explain
No
Yes
No
<-CONTINUED ON BACK ->
Please list medications you are currently taking:
Describe your pain (check all that apply)
Dull/Ache
Burning
Pins & Needles
Stiffnes
How often do you experience pain?
0-25% of the day
75-100 % of the day
Are your symptoms:
Stabbing
Other
25-50% of the day
All of the time
Getting better
Numbness
50-75% of the day
Getting worse
About the same
Check the box or Circle the area below that best describes your pain. * Zero being no pain and ten being intolerable pain.
No Pain
0
Are you: Left Handed
1
2
Right Handed
3
4
5
6
7
8
9
10 (Intolerable Pain)
?
What activities or positions make your problem better?
What activities or positions make your problem better?
Do you exercise?
Yes
No
Please list any sports/recreational activities you do:
Anything you would like the therapist to discuss/know:
_______________________________________________
Patient Signature
____________________
Date