RETURNING PATIENT FORM
Name:______DOB:______
Gender M / F SSN:______Phone:______
Please update any information that has changed since your last time here.
Address:______
Best contact phone:______Other phone:______
Marital Status: M / S / D / W Name of Current insurance:______
Are you receiving or have you received home health care recently? Y / N
Have you received OUTPATIENT physical therapy during this calendar year? Y / N
INJURY INFORMATION: Date of Injury______Location______Surgery date______
Cause: Auto accident / Work / Sports / Other:______Referred by:______
HEALTH HISTORY: Please circle all that apply to you.
Irregular Heart Beat Osteoporosis Smoker Kidney Disorder Other:______
Chronic Bronchitis Emphysema Cancer Liver Disorder ______
Heart valve problem Pacemaker Arthritis High Blood Pressure ______
Heart surgery Blood disorder Angina Diabetes: Insulin / Glucose ______
Heart attack GI disorder Stroke Seizures Allergies:______
CANCELLATION /NO SHOW POLICY
Please call our office with at least 24 hours notice if you need to cancel or change your appointment. You will be responsible for a $75 Cancellation Fee after the first offenseUNLESS you reschedule for the SAME or NEXT day. I am aware and agreeable to Active Physical Therapy’s cancellation policy:
Signature:______Date:______
FINANCIAL RESPONSIBILITY
I assign all medical benefits and authorize my insurance carrier(s) to issue payment directly to Active Physical Therapy, PLLC and/or my Therapist. I understand that Active will bill my insurance carrier(s) directly for services rendered. However, if the insurance carrier(s) should deny responsibility for these claims, I understand I will be held responsible. Failure to pay bills in a timely manner will result in a 40% account increase to compensate Active for collection agency fees. I further authorize the release of my physical therapy records to insurance companies in order to process claims.
Signature:______Date:______
PRIVACY PRACTICES
This acknowledgement reflects the privacy standards set forth by the Department of Health and Human Services. A copy of
Active Physical Therapy's privacy practices is located at the front desk. You may also request a copy for yourself.
Signature:______Date:______