2525 Colonial Drive Suite B Helena, MT 59601

2525 Colonial Drive Suite B Helena, MT 59601

Phone: 406-449-4279  Fax: 406-449-8043

Website:

Motor Vehicle Patient Registration

First Name: ______MI: ______Last Name: ______

Mailing Address: ______City: ______ST: ____ Zip: ______

Patient Gender:Male Female Marital Status:MarriedSingleWidowedChild

Patient DOB: ______Patient Social Security Number: ______

Home Phone: ______Work Phone: ______Cell Phone: ______

Email Address: ______

Primary Doctor: ______Primary Doctor Phone: ______

Emergency Contact

First Name: ______Last Name: ______

Emergency Phone: ______Relationship to emergency Contact: ______

Employment/School Information

Employment Status: Full Time Part Time Retired Student Disabled Not working due to Injury

Employer/School: ______Job Title: ______

Supervisor: ______Phone: ______

Driver's License #: ______Driver's License State: ______

Motor Vehicle Insurance Information

Have you RECIEVED Physical Therapy at any other Physical Therapy Office this year? Yes No

If, Yes Where ______When ______Phone Number______

Motor Vehicle Insurance Name: ______

Mailing Address:______City: ______ST: ____ Zip: ______

Adjuster Name: ______Adjuster Phone #: ______

Adjuster Fax#:______Date Of Injury: ______

State of Injury: ____ Claim Number: ______

Personal Insurance Information

Insurance Company Name: ______

Name of Card Holder: ______DOB of Card Holder: ______

Relationship to Card Holder: Self Spouse Parent Other______

Group Number: ______ID Number: ______

Signature of Patient: ______Date: ______

Guardian Information

Name of Guardian: ______Relationship: ______

Phone Number: ______Email Address: ______

Signature of Guardian: ______Date: ______

Reason for Visit

Date: ______

Name: ______Date of Birth: ______

Reason for Visit: ______

Assignment and Release

I hereby authorize my insurance benefits to be paid directly to the Provider. I also authorize the Provider to release any information required by the insurer for said payment. I am financially responsible for non-covered service. I further authorize Harrington Physical Therapy, PC to access any part of my records from my physician's office for continuity of care purposes and/or for the adjudication of all claims relating to payment of service. Records may be accessed in hard copy or by computer. I fully understand that only staff with a "need to know" based upon their job functions will have access to my records.

It is understood that my medical record and those acquired from other facilities with my permission, will be held in strict confidence and will not be released to any other party without my expressed written authorization.

I understand that should I default on payment of my account, and collection agency service be required, all cost of collections, including attorney fees will be added to the balance on my account.

X______X______

Patient's Signature Date

I hereby authorize Harrington Physical Therapy, PC to photograph/videos me and to store those photographs/videos in my medical chart as part of my evaluation and/or treatment. I understand that said photographs/videos will not be used for any purposes other than medical care and will not be release to any party other than those authorized by myself.

X______X______

Patient's Signature Date

Notice of Privacy Practices

Examples of Disclosure for Treatment, Payment and Health Operations

We will use your health information for treatment. For example: Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his/her expectations of the members or your healthcare team. Members of your healthcare team will then record the actions they took and their observation. In that way, the physician will know how you are responding to treatment.

We will use your health information for payment. For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

We will use your health information for regular health operations.For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide. Business associates: There are some service provided in our organization through contacts with business associates. Examples include physician service in the emergency department and radiology, certain laboratory test, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to ur business associate so that they can perform the job we've asked them to do and bill you or your third-party payer for services rendered. To protect your helath information, however, we require the business associate to appropriately safeguard your information.

WRITTEN ACKNOWLEDGEMENT

I acknowledge that I have reviewed the Notice of Privacy Practices which provides a description of information uses and disclosures. I understand that I have the right to request restrictions as to how my health information may be used or disclosed, that the organization is not required to agree to the restrictions I request.

X______X______

Signature of Patient or Legal Representative Date

X______X______

Witness Date

Release of Authorization to Use and Disclose Health Information

I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or health care provider, the release information no longer will be protected by federal privacy regulations.

By signing this authorization you acknowledge and agree that nearly all treatment performed at Harrington Physical Therapy, PC is done in an open setting where incidental disclosures may occur. Private consultations are available on request. You also agree that Harrington Physical Therapy, PC may use or disclose your personal health information for referral to other health care providers with your permission, any billing or collection activates or proceedings. Additionally there maybe communication via Text, Email or leaving a voice mail regarding scheduling of appointments, your health benefit coverage and related discussion of your care, or phone or mail notifications of any internal office promotions.

Patient Name:______DOB: ______

Persons/Organizations Providing the information: Harrington Physical Therapy, PC

Identify yourself, family members, doctors or other persons who are or will be involved in your care or payment for health care and with whom you authorize us to share your health information:

Name / Relationship to You / List of Information to be Shared / Fax Number
PATIENT / ALL INFORMATION
Emergency Contact

The patient or the patient's representative must read and initial the following statements:

1.) I understand that this authorization will Expire on _____/_____/______(DD/MM/YY)

Initials: ______

2.) I understand I may revoke this authorization at any time by notifying the providing organization in writing, but if I do it won't have any effect on any actions they took before the received the revocation.

Initials: ______

You have the right to revoke this Authorization at any time, provided that you do so in writing and except to the extent that we have already used or disclosed the information in reliance on this Authorization.

Unless revoked earlier or otherwise indicated, this Authorization will expire 180 days from the date of signing or shall remain in effect for the period reasonably needed to complete the request.

I have reviewed and I understand this Authorization. I also understand that the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer be protected under federal law.

Signature: ______Date: ______

Description of Representative's Authority: ______

Date: ______

DATE: ______

PATIENT or Guardian NAME ______

DOB: ______

Due to variable billing associated with motor vehicle accidents, you have been asked to provide both auto insurance information and personal health insurance information.

Frequently, automobile insurance has a relatively low maximum medical benefit which can be exhausted rather quickly once doctor, radiology, hospital bills, etc. are submitted.

If MHPT receives a denial from the motor vehicle insurance, for our services to you, we will offer to bill your health insurance. Any amounts not covered by your health insurance become your responsibility to pay.

If you do not provide health insurance information, a statement will be sent directly to you for the balance due.

Payment is required upon receipt of our statement.

Please be advised, regardless of who is at fault for the accident, you are responsible for payment of any treatment rendered to you by Manger Harrington, PT.

Thank you for your understanding.

Signature: ______

Date: ______

Maggi Kuxhaus

Healthcare Reimbursement Specialist

MHPT- AR Dept. manager

406-449-4279