Patient/Client Information Acct#______
Patient Name:Date of Birth: / SS#:
Address:
City:
State: / ZIP:
Home Phone: / Work:
Marital Status: / S M D W Cell:
Employer:
Occupation/Title:
Emergency Name
Relationship: / _____ Phone #
Patient’s Email address:
Injury Information
Date of Injury: smptom / Surgery date:Last Day Worked: / Date returned:
Injury: How
Injury: Where
Is Accident: / Work Related: Y N Motor Vehicle: Y N
Body part:
ICD #’s:
Have you had PT or Chiropractor visits this year or in previous year? Y N If yes, how many visits? ______
Workers Comp Information
MCO Self-Insured US Dept. Labor
MCO/Self Insured:
Claim # / Date of Injury:
VOC Manager:
Phone: / Fax:
Case Manager:
Phone: / Fax:
Employer:
Address:
City/State: / ZIP:
Job Available: Yes No Unknown
Attorney Information
Attorney Name:Address:
City:
State: / ZIP:
Phone: / Fax:
[ ] Check PTOS to see if patient is a return patient : Y or N
If yes, old PTOS Acct #?______Balance$______
Service Requested (check all that apply)Physical Therapy
Referring Doctor Information
I am self-referring for physical therapy
I would like the below physician notified
I DO NOT want my physician notified
Physician of Record:
Referring MD:
Primary MD: / ______
Date first consulted MD:______/ Next MD appt: ______
Besides your referring Physician, is there anyone else
you would like us to send updated information to?
Billing Information – Primary Insurance
Insurance Name:Insurance Phone:
Cardholder Name: / DOB:
Address:
Patient Relationship: / 1) Self 2) Spouse 3) Child 4) Other
Cardholder Employer:
Group #: / ID #
Billing Information – Secondary Insurance
Insurance Name:Insurance Phone:
Cardholder Name: / DOB:
Address:
Patient Relationship: / 1) Self 2) Spouse 3) Child 4) Other
Cardholder Employer
Group #: / ID #
Referring Company
Referring Company:______Contact Name:
Phone:______/ Fax:
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Health Insurance Portability and Accountability Act:I have read and understand Sports Therapy, Inc.'s HIPAA policy, and understand a copy will be provided to me upon request.
Signature Of Patient, Parent, or Guardian:______Date:______
Patient Consent:
I hereby give my consent to receive Physical and/or I hereby give my consent for my minor/daughter/son,______,
Occupational Therapy at Sports Therapy, Inc. to receive Physical and/or Occupational Therapy at Sports Therapy ,Inc.
Signature Of Patient, Parent, or Guardian:______Date:______
TO: SPORTS THERAPY, INC.
1. Release of Information:
I hereby authorize you to release to any insurance companies, their intermediaries or carriers responsible for paying charges incurred by me, any and all medical reports or bills generated as a result of my treatment.
2. Request for Payment:
I hereby authorize you to request payment from any insurance company and/or any accident/auto policies for medical services rendered to me by the filing of the claim forms and other documents which are or may be required to obtain payment from the insurance companies which cover the medical services rendered to me.
3. Assignment of Benefits:
I understand that I am financially responsible for the costs of all services provided to me including the balance remaining after payment of possible insurance benefits and, I further authorize any insurance company which insures the payment for services rendered to me to be issued directly to: Sports Therapy, Inc.
I hereby authorize my attorney to issue payment directly to the above named clinic for any and all bills outstanding, arising out of my accident indicated. I acknowledge that any medical insurance filed for services related to this accident, will be reduced only by actual payments made by my insurance carrier and not reduced by any usual, customary, and reasonable level or provider contract obligations with my medical insurance carrier. If for any reason there is a difference when my attorney settles, or if a settlement was not reached, balance shall be paid by me and shall be my sole responsibility at time of legal settlement of my case.
4. Patient Responsibility:
I agree that payment of any fees incurred by me for medical services rendered to me, which fees are not paid (in part or in full) by or under my medical insurance companies, their intermediaries or carriers, shall be paid by me and shall be my sole responsibility.
5. Cost of Collection:
I agree to pay all fees and/or court costs and/or attorney fees and/or interest on all late and delinquent fees incurred by me for medical services rendered to me by: Sports Therapy, Inc.
6. Interest on Unpaid Balance:
Any unpaid balance remaining after 30 days will accrue interest at the rate of 1.5% per month.
7. Social or Vocational Services:
I hereby authorize your social or vocational service provider under contract to review my chart on a monthly basis to determine any need for social or vocational services and make necessary recommendations thereof.
8. Receipt of Financial Policy:
I have received and understand the Financial Policy letter.
9. Insurance Verification Form:
Sports Therapy, Inc. has verified insurance benefits available to me and I have received a copy of their form reflecting such coverage. I understand that the verification provided by my insurance company to Sports Therapy, Inc. is not a guarantee of coverage and Sports Therapy, Inc. does not accept responsibility for its accuracy. I understand that my payment may be higher if this information is not correct.
Please initial:
_____This treatment is not due to an auto accident
_____This treatment is not due to a workers comp related injury
I have read and fully understand the information outlined in the paragraphs above.
Patient’s signature:______Date:____/____/____
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