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Delray - Patient Intake Form

Please fill out the form below, completely. All fields marked with a red asterisk (*) are required.
You can also download it here, fill it out by hand, and bring it to your next appointment.

PATIENT INFORMATION

Name:

Date:

Street Address:

Apt. #:

City:

State:

Zip:

Email:

Birth Date:

Age:

Home phone:

Work:

Cell:

Occupation:

Refering Physician:

Have you had or currently having any PT or Home Health this year? If so, when

Have you been treated at Absolute Rehab/ Premier Physical Therapy before? YES NO If yes, when and by whom?

How did you hear about Absolute Rehab/ Premier Physical Therapy ? Family Friend Internet Doctor

If a family or friend referred you, please list their name here so we can thank them:

Emergency Contact:

Relationship:

Phone Day:

Evening:

AUTHORIZATION TO RELEASE INFORMATION AND CONSENT TO TREATMENT

I hereby authorize the release of any information by telephone or in writing, including reports of diagnosis, treatment, prognosis, recommendations, benefits payable, and any other data pertinent to my treatment, by Premier Physical Therapy to my physician(s) as well as any organization responsible for payment of my account. I authorize my insurance company to pay medical benefits directly to Premier Physical Therapy in instances where a claim has been filed by Premier Physical Therapy on my behalf. I hereby consent to such treatment procedures and patient care which, in the judgment of my therapist and/or physician, may be considered necessary or advisable while I am a patient of Premier Physical Therapy. I understand that I play a role in this care and can question or refuse treatment at any time.

Print name of Patient or Guardian

Signature of Patient or Guardian

Date

GENERAL POLICIES

Please notify the front desk if there are any changes to your address, phone number or insurance plan[cite: 212, 214].
Out of courtesy to your fellow patients, please refrain from using your cell phones in the treatment and gym areas[cite: 216].
To ensure your safety, please do not use any equipment in the gym that you have not been instructed in...[cite: 230].

I have read, understand, and agree to all the above policies.

CURRENT HISTORY/SYMPTOMS

Name:

Describe your current symptoms and/or activity limitations:

Describe when and how your injury occurred:

Have you had any diagnostic tests? MRI x-ray bone scan

Results:

What, if any, treatment have you had for this problem Physical therapy chiropractic acupuncture other

When and how frequently did/do you have this treatment?

Did this treatment help? (Please explain)

Have you had similar symptoms in the past? If yes, please describe and list the date prior to this recent incident or flare that you had these symptoms:

Please indicate where your pain is located and what type of pain you feel at the present time. Use the symbols below to describe your pain. Do not indicate areas of pain which are not related to your present injury or condition.

Body anatomy chart showing front and back views for pain notation

Rate your pain on a visual scale (0-10, 0=no pain, 10=excruciating):

Worst:

Past 2-4 wks:

Past 24 hrs:

At this moment:

Indicate the nature of your pain/symptoms (check all that apply): sharp dull shooting aching stabbing burning deep superficial

Are your symptoms worse in the: morning afternoon evening inconsistent constant

Are your symptoms: improving worsening stable

What actions, activities or positions aggravate your symptoms/pain?

What actions, activities, positions, treatments, or medications ease your symptoms/pain?

Special questions: Please mark "no" if appropriate. Otherwise, please explain in the lines provided.

No My pain is constant (24 hours/day, 7 days/week)

No My pain travels (e.g. from neck to hand or back to foot)

No I have a metal implant or surgical hardware in my body

No I have a pacemaker or other implanted device in my body

No I have weight-bearing restrictions given to me by my doctor

No I have osteoporosis or a history of fractures

No I have contact allergies to adhesives, latex, rubber, ice, etc.

No I have a heart condition and was told not to do physical activity

Please list your current medications (prescription and over the counter):

Is your injury work related?

Motor vehicle accident?

Does your occupation consist of:

Other significant lifestyle physicality:

What are your goals for physical therapy?

MEDICAL/INJURY HISTORY

Have you EVER been diagnosed as having any of the following conditions?

Please use the following lines to explain any circled above, or any medical problem not listed above:

Please describe the injuries for which you have been treated (broken bones, dislocation, sprains, etc) including dates:

Have you ever had surgery?

If yes, please list reason and dates:

Is there any history of heart disease, diabetes or cancer in your family? Yes No

If yes, please explain:

PATIENT AGREEMENT

Please read and sign acknowledgement of this consent:

We appreciate your consideration in choosing Premier Physical Therapy & Sports Medicine for your rehabilitation needs, and we are committed to providing you with the best care possible[cite: 375]. To achieve this, we need your assistance and understanding of our scheduling, cancellation, and financial policies[cite: 376].

Physical therapy is a partnership between patient and therapist. At the onset of your care, we will discuss a recommended treatment plan, possible lifestyle changes, and a home exercise program to help facilitate your healing and achieving goals[cite: 377].

SCHEDULING AND CANCELLATION POLICIES

Please schedule your appointments in advance. Our schedule fills up quickly and we want to ensure that you get the times that you need.
Please be timely with your appointments. We will make every effort to respect your time, and we expect that you will do the same for both your therapist and your fellow patients. If you are late for an appointment, your one-on-one time with your PT will still end at the scheduled time. If you are more than 15 minutes late for an appointment, we will attempt to accommodate you for another time, but it may result in a cancellation fee of $100.
Premier Physical Therapy realizes that many things arise in your busy schedules. That is why we allow for a 1-time courtesy on the cancellation fee. However, after that we require that you, please provide 24 hour notice for cancellation or rescheduling of an appointment. Failure to comply will result in a cancellation charge of $100 due in full at your next visit. If you "no-show" or "late cancel" for 3 consecutive appointments you will be removed from the schedule due to noncompliance.
Your insurance company will not pay for any cancellation charges due to missed appointments.
All scheduling and cancellations must be done in person or over the phone at the front desk. Emails and texts should not be used for scheduling or cancellations as these are not checked regularly. Your physical therapist cannot schedule or cancel appointments for you.

Initial

PAYMENT POLICIES

All treatment sessions, co-insurance, deductible and equipment payments are due at the time of service or via credit card on file for all patients. Supplies and equipment purchased from Premier Physical Therapy as part of your treatment are not billable to your insurance, and since they are sold at cost, please pay with check or cash. For supplies, all payments must be in cash or check only.
We accept Cash, Check, Debit and Credit Cards. A $35.00 service fee for the processing of any returned checks will be applied to your account.
For supplies, all payments must be in cash or check only. We accept Cash, Check, Debit and Credit Cards[cite: 395].
If payment is sent to you directly, please endorse the check to Premier Physical Therapy and provide us with a copy of the EOB.
Any insurance policy deductibles or claims denied by your insurance carrier will be charged to your credit card once we have been sent proper notification by your major medical insurance carrier. A paid invoice and copy of the receipt will be sent to you for your records. We will advise prior to charge.
Premier Physical Therapy reserves the right to charge interest at the legal prevailing rate and to apply late payments or service fees for multiple payment plans as necessary to manage the collection of your account.
There will be a 3% credit card processing fee automatically applied to all credit card and debit card transactions.

Initial

INSURANCE POLICIES

As a courtesy to you, we will verify your insurance coverage and benefits with your primary and secondary insurance carriers, with the understanding that verification is only a quote and not a guarantee of payment.
Most insurance companies cover our services as an out-of-network provider providing your deductible has been met. Premier Physical Therapy will provide you with an insurance-readable bill to submit to your insurance company for reimbursement if you would like to self-submit. There are some insurance companies that we will bill directly on your behalf, determined on a case-by-case basis.
Your insurance contract is an agreement between you, your employer, and your insurance company. We will render services on the assumption that charges will be covered by your insurance company. However, you are ultimately responsible for payment for all services rendered, unless otherwise provided by law. You will be responsible for all deductibles, coinsurance amounts, and services not covered by your insurance company, including those denied because the insurance deems them as "not covered", "not medically necessary", "not authorized", "maintenance", "not supported by documentation" or otherwise non-payable benefit.
Not all services are covered benefits in all insurance contracts. Some insurance companies arbitrarily select certain services they will not cover. The fact that your insurance company may not pay for a particular item or service does not mean that you should not receive it. Your doctor and physical therapist determine your treatment plan based upon their educated opinions as to what is most appropriate care to get you better quickly. This includes, but is not limited to, evaluations, re- evaluations, electric stimulation, ultrasound, taping, therapeutic exercise, therapeutic activities, and neuromuscular re-education. We will do our best to work with you by utilizing the most traditionally covered codes by insurance companies.
We will help by providing information to your insurance company necessary for them to process your claims, but we do not accept responsibility for settling the claim with your carrier. If you receive any denials or explanation of benefits from your insurance company, please notify us immediately for quicker processing.
If payment is delayed, reduced, or denied by your insurance carrier beyond 90 days, you will be responsible for settling your balance with us.

Initial

We will be happy to assist you with any questions you may have regarding your account. Please contact our Office Manager, Monday- Friday from 8am to 4pm. @ 561-241-4411.

I have read the above information and agree with the financial, scheduling and cancellation policies of Premier Physical Therapy & Sports Medicine

Print name of Patient or Guardian

Signature of Patient or Guardian

Date

MEDICAL RECORD RELEASE FORM

I hereby authorize the following information to be released from the medical record of:

Patient Name:

DOB:

Address:

Phone #:

I request that my information be released to Premier Physical Therapy & Sports Medicine from

Doctor Name/Name:

Fax #:

Requesting: Release of Insurance/Benefit information

Medical Records

Surgical Records

MRI/CAT Scan Reports

X-Rays

Requesting updated prescriptions

Signature

Date:

NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGMENT OF RECEIPT

Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.

If you have any questions about out Notice of Privacy Practices, please contact our Compliance Office at:
1400 SE Goldtree Drive, Suite 205 Port St. Lucie, FL 34952 Ph. (772) 335-7966

Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting us at the above address or our Practice.

My signature below indicates that I have been given the Notice of Privacy Practices for PREMIER PHYSICAL THERAPY & SPORTS MEDICINE. I acknowledge that the Notice of Privacy Practices is posted at the location in which I am receiving treatment as well as on their website at premier-therapy.com and that I have read and understand the notice. I further acknowledge that I have the right to request a copy of the notice and one will be provided to me. I recognize that outside of purposes for treatment, payment, certain healthcare operations or as permitted or required by law, I must give my written authorization for PREMIER PHYSICAL THERAPY & SPORTS MEDICINE to release any of my protected healthcare information.

Patient Name:

Signature:

Date:

(Patient / Parent / Conservator / Guardian)

Disclosures to Individuals Involved in Patient's Care

There may be times when it is necessary for an individual directly involved in your care to call the facility to inquire about your personal health information or billing information. Please complete this section.

I authorize PREMIER PHYSICAL THERAPY & SPORTS MEDICINE to disclose my health information that is directly related to my current treatment at PREMIER PHYSICAL THERAPY & SPORTS MEDICINE to the individual(s) listed below for purposes of their role in my treatment or payment for the health services that I have received. Such persons involved in your care may include spouse, children, blood relatives, roommates, boyfriends/girlfriends, domestic partners, neighbors, friends and colleagues.

Name

Relationship

Name

Relationship

Name

Relationship

I DO NOT wish to have my health information disclosed to individuals involved in my care.

Signature:

Date:

PATIENT SCHEDULING PREFERENCES

Patient Name:

At Premier Physical Therapy, we do our best to accommodate your physical therapy appointments with your personal schedule. Please understand your appointments are pertinent to your treatment plan in meeting your physical therapy goals.

NOTE: The frequency of appointments can only be determined after completion of your initial evaluation. The frequency may be 3 times a week for the initial appointments, but will most likely be 2 times a week for the majority of your treatment plan.

Please fill out the schedule to designate your scheduling preferences, using the key symbols:

[X] Days/times in which you will be NOT AVAILABLE
[1] Your 1st choice for appointment days/times (2 x week)
[2] Your 2nd choice for appointment days/times (2 x week)

Time	Monday	Tuesday	Wednesday	Thursday	Friday
8:00am-9:00am
9:00am-10:00am
10:00am-11:00am
11:00am-12:00pm
1:00pm-2:00pm
2:00pm-3:00pm
3:00pm-4:00pm
4:00pm-5:00pm

**If there are any specific dates in which you will not be available (i.e.: vacations, doctor appointments) please write them below:

Directions

3100 S. Federal Hwy., Ste A

Delray Beach, Fl. 33483

Ph: 561-241-4411

Fax: 561-241-4211

From North:

I-95 South or Jog Rd. to Linton Blvd

Take Linton East to Old Dixie Road or Federal Hwy(US 1) - Take Right Turn onto Old Dixie Road or Federal Hwy.

From OLd Dixie Road : Make a Left at a Traffic Light onto Lindell Blvd. We are in the Shoppes at Latitudes on the Left. Door Entrance is in the Middle of the Building in the Parking Lot.

From Federal Hwy: Continue South, Turn Right on Lindell Blvd. We are in the Shoppes at Latitudes on the right. Door Entrance is in the Middle of the Building in the Parking Lot.

From South:

Take Congress Ave. North and turn left on SW 10th Ave. Take SW 10th Ave. allthe way down to Old Dixie Road. Continue on Old Dixie Road past Linton. At the next Traffic Light turn Left on Lindell Bivd. We are in the Shoppes at Latitudes on the Left. Door Entrance is in the Middle of the Building of the Parking Lot.

From South:

I-95 North to Yamato Road.

Take Yamato East to North Dixie Hwy. Turn Left (North)onto Dixie Hwy. About 2 miles on the right at the Traffic Light turn right at Lindell Blvd. we are in the Shoppes at Latitudes on the Left. Door Entrance is in the Middle of the Building of the Parking Lot.

**OUR OFFICE IS LOCATED ON THE 2ND FLOOR**

Left of the Elevator

Delray - Patient Intake Form

PATIENT INFORMATION

AUTHORIZATION TO RELEASE INFORMATION AND CONSENT TO TREATMENT

GENERAL POLICIES

CURRENT HISTORY/SYMPTOMS

MEDICAL/INJURY HISTORY

SOCIAL HISTORY

PATIENT AGREEMENT

SCHEDULING AND CANCELLATION POLICIES

PAYMENT POLICIES

INSURANCE POLICIES

MEDICAL RECORD RELEASE FORM

NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGMENT OF RECEIPT

Disclosures to Individuals Involved in Patient's Care

PATIENT SCHEDULING PREFERENCES

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