Rozina Smith Physical Therapy Private Insurance Forms

Rozina & Smith Physical Therapy Patient Forms

INSTRUCTIONS

1. Accurately type your information in the patient information form. You can press Tab to go forward from box to box or Shift + Tab to move back a box.

2. When you are finished entering all of your information, please save the document to your computer.

3. Print out and sign and initial where the lines are highlighted.

4. Bring the printed document to the clinic for your first appointment.

WHAT YOU WILL NEED FOR YOUR APPOINTMENT:

1. Appropriate clothing allowing access to the area to be treated - for example shorts, loose fitting sweat pants, t-shirt or tank top.

2. The attached paperwork.

3. Current prescription from your doctor.

4. Insurance card.

5. Medication list.

Please be sure to get a copy of all your appointments when you come in. If you have any questions or concerns please feel free to call our office (909) 985-8686.

PATIENT DEMOGRAPHICS

Last Name: First Name: MI:

Social Security: Gender: Date of Birth: Age:

Marital Status: Height: ft in. Weight: lbs

Address: City: State: Zip:

Email Address:

Home Phone: Primary Y N Work Phone: Primary Y N

Cell Phone: Primary Y N Student/Employment Status:

Spouse Name: Phone Number:

Emergency Contact: Relationship: Phone:

Responsible Party: Phone:

Driver's License Number: State Issued:

Employer Name: Occupation:

Address: City: State: Zip:

Employer Phone:

How did you hear about us?

INSURANCE INFORMATION

Primary Insurance: Policy Holder Name:

Relationship to Policy Holder: Policy Holder DOB:

Secondary Insurance: Policy Holder Name:

Relationship to Policy Holder: Policy Holder DOB:

MEDICAL HISTORY

Describe any other conditions or precautions:

FALL HISTORY

Is this injury a result of a fall in the past year? Y N Date of fall:

Have you had two or more falls in the last year? Y N Date of falls:

SURGICAL HISTORY

Body Region: Surgery Type: Date of Surgery:

Body Region: Surgery Type: Date of Surgery:

CURRENT MEDICATIONS

Drug: Dosage: Reason for taking:

Drug: Dosage: Reason for taking:

Drug: Dosage: Reason for taking:

CURRENT SYMPTOMS

During the past month, have you often been bothered by feeling down, depressed or hopeless? Y N

During the past month, have you often been bothered by little interest or pleasure in doing things? Y N

The above information is correct to the best of my knowledge.

Witness: Date:

Date:

Office Use Only

Is this something with which you would like help?

Yes - today
Yes - but not today
No - I do not want help

Patient Signature:

Parent/Guardian (If patient is a minor):

Physical Therapist Initials:

PAIN INTENSITY / BODY CHART

Please check the number on the pain intensity scale that best describes your pain at the present time.

Draw the location of your pain on the body charts above. If you have any other symptoms, such as tingling or numbness, draw these as a dotted line.

NAME: DATE:

Please describe the details of your injury, including the date of injury and any treatment of the injury:

OUR FINANCIAL POLICY

Please initial following each statement to authorize.

Insurance is a contract between the patient or guarantor and the insurance company and Rozina and Smith Physical Therapy only bills insurance as a courtesy to the patient. I am financially responsible to Rozina and Smith Physical Therapy for services rendered.

I fully understand that Rozina and Smith Physical Therapy may not accept my insurance fees as payment in full. This would lead to my receiving a bill for deductibles, co-payments, co-insurance and non-covered items. I agree to pay for any such balance.

I understand that it is my responsibility to obtain all necessary referrals from my doctor or Primary Care Physician as required by my insurance company. Prescriptions must be kept current from month to month. In the event that services are rendered and later denied by my insurance company(s) for lack of referral/pre-authorization, I understand it will be my responsibility to pay Rozina and Smith Physical Therapy for services rendered.

Unless appointments are canceled at least 24 hours in advance, our policy is to charge $25.00 for missed appointments. This charge is not covered by insurance and is your responsibility to pay.

ASSIGNMENT OF BENEFITS

I have read the Financial Policy. I understand and agree to this policy. I hereby authorize my insurance company to pay all benefits directly to:

Rozina and Smith Physical Therapy

846 West Foothill Blvd., Suite C

Upland, CA 91786

Patient Signature: Date:

Parent or Guardian, if patient is a minor:

PATIENT CONSENT TO TREAT

I authorize Rozina and Smith Physical Therapy Center to render appropriate treatment to me. I understand appropriate personnel will provide this treatment and that I have the right to refuse.

I authorize Rozina and Smith Physical Therapy Center to obtain or provide emergency care if conditions warrant it during a treatment session and I am unable to give consent (CPR or emergency care).

PATIENT INFORMATION ACKNOWLEDGEMENT

I have read and fully understand Rozina and Smith Physical Therapy’s Notice of Information Practices. I understand that Rozina and Smith Physical Therapy may use my personal information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to payment or treatment. I have been given an opportunity to obtain a copy of Rozina and Smith Physical Therapy’s Notice of Privacy Practices should I ask for it.

Patient Signature: Date:

Parent or Guardian, if patient is a minor: