Patient Intake Form

Patient Information

Name *: Date of Birth *:

Social Security #: Male/Female *:

Home Address *:

City *: State * : Zip Code *:

Contact Information

Cell *: Home: Email *:

Emergency Contact Information

Name *: Phone Number *: Relation *:

Work Information

Employer *:

Employer's Phone Number *:

Please check YES or NO and INITIAL for the following four questions:

Consent to Treat

I, the undersigned, hereby voluntarily authorize Premier Physical Therapy & Sports Medicine to perform outpatient diagnostic evaluation and/or procedures and to administer such outpatient therapy that is necessary and appropriate. I understand that physical therapy is not an exact science and no guarantee has been made as to the result of any treatment or care administered.

Authorization to Release Information

I, the undersigned, hereby voluntarily authorize Premier Physical Therapy & Sports Medicine and the attending physician to release information relative to any outpatient therapy treatment administered to any third-party payor(s) financially responsible for these services or my referring and/or primary care physician or therapist

Acknowledgment of Terms

By signing below, I attest that all the information given is true and accurate to the best of my ability and that I have read and understand the policies stated above.

PATIENT SIGNATURE *: Date *:

GUARDIAN SIGNATURE: Date:

Physical Therapy Attendance Policy (Please read thoroughly)

Premier Physical Therapy and Sports Medicine strives to provide each patient with the highest level of quality care while attempting to accommodate your schedule for your convenience.
Therefore, we provide reserved time slots for each patient with a specific therapist in order to minimize your waiting and assure continuity of your treatment. Your consistent attendance of the planned treatment regimen is paramount to your full recovery.

While we are sensitive to the fact that an emergency may occur in a rare instance, cancellations less than 24 hours prior to treatment along with patient no-shows, decrease our ability to accommodate the scheduling needs of the other patients. It also affects how we staff each location. Additionally, keeping your scheduled appointments is courteous to your therapist and other patients. We must ask for your full cooperation with the following policy:

• If you are more than 15 minutes late for your appointment and fail to notify us, treatment may be canceled, and a $50.00 fee charged for missing the appointment.
• A scheduled appointment MUST BE CANCELED AT LEAST 24 HOURS IN ADVANCE, or the fee will be charged for that appointment.
• Failure to show up for an appointment (“NO SHOW”) without notifying us will result in $50.00 fee for therapy appointments, $150.00 fee for Pelvic Foor and Lymphedema appointments and $300.00 fee for FCE appointments. No Show for Pelvic Floor follow up appointments will result in a $100.00 fee. Furthermore, 2 consecutive no-shows will result in the cancellation of all remaining scheduled appointments.
• THE PATIENT IS RESPONSIBLE FOR THE FEE, NOT THE INSURANCE/THIRD PARTY PAYER
• All cancellations and no-shows will be documented in your medical record and appropriately reported to your physician and insurance/third party payer.
• Repeated failure to comply with this ATTENDANCE POLICY will result in discharge from the practice. Your physician’s office will be notified.
• No cancellation fee will be charged if the missed appointment is made within the same week it was scheduled on a day you do not have another appointment scheduled.

We believe that this policy is necessary for the benefit of all our patients, so that we may continue to provide high quality treatment and service to everyone. All the staff at Premier Physical Therapy and Sports Medicine appreciates your anticipated adherence and cooperation with this policy. We wish you the best of luck with your treatment. We are here to help you attain all your goals and optimize your returns to all your pre-injury activities

Patient Acknowledgment/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 to of PREMIER PHYSICAL THERAPY & SPORTS MEDICINE to release any of my protected healthcare information.

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

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

Signature *: Date *:

YOU ARE RESPONSIBLE FOR:

Payment for all services rendered by Premier Physical Therapy & Sports Medicine. Although we will do our part to submit claims to your insurance company, it is your responsibility to know your benefit and coverage limits. If for any reason your insurance fails to reimburse Premier Physical Therapy & Sports Medicine you will be responsible for payment for all services rendered.

PRE-AUTHORIZATION AND REFERRALS:

It is your responsibility to know which services require pre-authorization. If your insurance plan requires a written referral from your Primary Care Physician (PCP) in order for physical therapy services to be initiated, you are required to provide this facility with the written referral prior to your first treatment.

INSURANCE PLANS WITH DEDUCTIBLES:

If you have an annual deductible, in which you must pay before your insurance company begins to cover services rendered, you will be responsible to make payment in full for all services rendered until you deductible has been met.

PLANS OF NON-PARTICIPATION:

We will provide the service of submitting claims to you insurer if we are non-participating. However, if payment is not received within 90 days from the date of service, charges for services rendered to you or your family member become your responsibility. You are responsible for your entire charge less any payment from you insurer. If we do no participate with your secondary (or any non -primary) insurer, you are responsible for that portion of the bill at the time of service.

COVERAGE LIMITATIONS OF YOUR HEALTH INSURANCE PLAN:

Your health insurance plan provides payment for physical therapy services with the following limitations:

PAYMENT TERMS:

Payment is due at the time of service for insurance co-payments, annual deductibles and any services deemed non-covered by your insurance company. We accept Cash, Check Money Orders, MasterCard, Visa, Discover and American Express.

IN SIGNING THIS POLICY:

You assign your insurance benefits directly to Premier Physical Therapy & Sports Medicine. You authorize Premier Physical Therapy & Sports Medicine to release any medical information for claims reimbursement or clinical purposes. You certify that all information given by you is correct to the best of your knowledge. Your signature on this document serves as "Signature On File"for all claims submitted to your insurance company for the services rendered at Premier Physical Therapy & Sports Medicine.

I (we), the undersigned, authorize and request that Premier Physical Therapy & Sports Medicine keep my signature and my credit card information securely on-file in my account. I authorize charge to my credit card for the balance due that my health plan has identified as my financial responsibility.

I do not wish to keep my credit card on file

PATIENT NAME *:

PATIENT SIGNATURE *: Date *:

GUARDIAN SIGNATURE:

(if patient is a minor) Date:

AUTO INJURIES, WORK INJURIES and PERSONAL INJURIES ONLY – please complete this section

WORKERS COMPENSATION PATIENTS PLEASE READ & INITIAL:

• Make ever effort to attend all of you scheduled therapy sessions. this will speed your recovery process.
• If you are unable to attend an appointment, please let us know 24-hours in advance so we can offer your treatment time to another patient and get your appointment rescheduled to a more convenient time.
• If you miss two or more appointments without cancelling, we will notify your physician, workers compensation insurance carrier and your employer that you are not attending your scheduled appointments. We also reserve the right to cancel all of your future appointments and require that you obtain a new referral from your physician to re-start your treatment.

INITIALS *: