Patient Information Form

Full Name ​(First, MI, Last)​: Date of Birth: ___/___/______

Nickname: ☐ Female ☐ Male

SSN:

Physical Address:

City/State:

Zip:

Mailing Address:

City/State:

Zip:

Phone:

Email:

Employer: Primary Care Physician:

Phone:

Referred By:

Phone:

Is this injury the result of motor vehicle accident?

⬜ Yes ⬜ No

Is this injury the result of an injury at work?

⬜ Yes ⬜ No

Address:

City/State:

Zip:

Policyholder Name:

Relationship to Patient:

Insurance Information **Please present insurance card at time of service.** Primary Insurance Plan:

Employer of Policyholder: ID#:

Group #:

Secondary Insurance Plan: Address:

City/State:

Zip:

Policyholder Name:

Relationship to Patient:

Employer of Policyholder: ID#:

Group #:

Office Use Only

☐ ​Copy DL front/back

☐ ​Copy Insurance front/back

☐ ​Insurance Verification

1

Financial Agreement

Thank you for choosing Adventure Physical Therapy LLC, a member of PT-MDKinect LLC. We will work with you to help you with your insurance claims, but would like you to understand our office policy regarding insurance assignment. Payment is expected at the time of service unless we accept assignment with your insurance company or previous payment arrangements have been made. For our office to accept insurance assignment, we ask that you read and sign the following. I acknowledge that it is my responsibility to: 1. Provide complete current information on medical insurance coverage. 2. Present a valid insurance card when requested. 3. Pay applicable copayment at the time of service. 4. Present a valid referral or authorization number for all services (if required by my insurance company). 5. Inform the office if the patient’s need for medical services is due to a motor vehicle, worker’s compensation or other accident. 6. Make payment within 30 days any balance on my account for any amount due such as deductibles, coinsurance, co-payments, or non-covered services. Explanation of Benefits (EOB) Our office is a member of the P3 Kinect Network for billing purposes. We are letting you know because the bills you receive from us may read: P ​ T/MD Kinect​ or ​Partners in Health,​ and/or have the name of our P3 Kinect network supervising physician on them. You may receive bills from ​Diagonal Medical Billing​. Payment Policy

I am ultimately responsible to pay the medical bill if my insurance company does not honor the assignment of benefits in whole or in part. ​Payments may be arranged. I agree that if it becomes necessary to forward my account to a collection agency, I will also be responsible for the reasonable cost of collection, to include any attorney fees. Your signature below indicates: 1. You understand and accept our policy of assignment of insurance benefits. 2. You attest to the accuracy of the medical insurance coverage information. 3. You authorize this office to release medical information necessary to process your claims and appeals. 4. You authorize payment of medical benefits to Adventure Physical Therapy LLC, a member of PT-MDKinect LLC. 5. You have read and understand the Payment Policy. ______________________________________ Print Name of Patient or Responsible Party

Date:

____________________________________ Signature of Patient or Responsible Party

2

Consent to Treat Privacy Practices HIPAA Medical Information Release Consent to Treat I authorize Adventure Physical Therapy LLC to provide treatment as deemed necessary for the care of the below named Patient.

Acknowledgement of receipt of notice of Privacy Practices By signing below, I acknowledge that I have been offered or provided a copy of Adventure Physical Therapy LLC Notice of Privacy Practices. These are always available on our clinic website at www.adventurephysicaltherapy.com.

HIPAA Medical Information Release Release of Information​:

I authorize the release of information from Adventure Physical Therapy LLC, a member of PT-MDKinect LLC, including the diagnosis, records, examination rendered to me and claims/billing information. It is helpful if you put your physician and/or referring party’s name. This information may be released to: ⬜ Spouse/Partner:____________________________________ ⬜ Child(ren):____________________________________ ⬜ Other:____________________________________ ⬜ Information is not to be released to anyone. This ​ ​Release of Information​ will remain in effect until terminated by me in writing. Your signature below indicates: 1. You understand and agree to the Consent to Treat 2. You read and understand the Acknowledgement of receipt of Notice of Privacy Practices 3. You read and understand the Medical Information Release.

Patient Signature:

Date:

Witness:

Date:

3

Email Policy Cancellation and No-Show Policy

Appointment reminders We send appointment reminders by email, using the email you supplied on the Patient Information Form.

⬜ ​Check this box to be added to our email list to be notified of future events at Adventure Physical Therapy LLC. (you may unsubscribe at any time)

Cancellation and No-Show Policy When you do not show up for your appointment, three people are hurt: 1. You​, because you don’t get the treatment you need 2. Your therapist,​ who now has a space in their schedule 3. Another patient,​ who could have been scheduled during your appointment Adventure Physical Therapy LLC requires 24 hours notice in the event of a cancellation. There is a $40 charge for all cancellations without 24 hours notice. This will be charged to you personally and cannot be billed to insurance. For Worker’s Compensation and Personal Injury patients: documentation of any missed appointments is forwarded to your Case Manager and Primary Physician, and this could jeopardize your claim. Thank you for your cooperation. We look forward to working with you. Your signature below indicates: 1. You agree to receive appointment reminders by email 2. You read and agree to the Cancellation and No-Show Policy.

______________________________________ Print Name of Patient or Responsible Party

_____________ Date

______________________________________ Signature of Patient or Responsible Party

4

Patient Medical History Today’s Date: ___/___/______

Full Name ​(First, MI, Last)​:

Date of Birth: ___/___/______

Emergency Medical Contact Name:

Phone:

Any specific wishes regarding possible emergency care?_________________________________________ _______________________________________________________________________________________________ Medical History: Have you ever had any of the following? ⬜ ⬜ ⬜ ⬜ ⬜ ⬜ ⬜

Heart Problems Cancer Diabetes Seizures Previous surgeries Urinary Incontinence Pregnancy

⬜ ⬜ ⬜ ⬜ ⬜ ⬜ ⬜

Pacemaker High Blood Pressure TB/HIV/Hepatitis Bleeding Disorders Allergies Osteoporosis/Osteopenia Joint Pain

If you checked ‘Yes’ to any of the above conditions, please explain: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Please list all current medications or provide a list with dosages: _________________________________________________________________________________________________ _________________________________________________________________________________________________ Describe your current physical complaint: Date of injury: _________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ What are your goals for physical therapy? _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Circle your ​highest ​pain level in the last 24 hours: no pain (0) 1 2 3 4 5

6

7

8

9

10 (worst pain imaginable)

Circle your ​lowest ​pain level in the last 24 hours: no pain (0) 1 2 3 4 5

6

7

8

9

10 (worst pain imaginable) 5

Patient Specific Functional Scale

Patient Name: ______________________ Date of Birth: ___/___/______ We want to know what activities in your life you are unable to perform, or are having the most difficulty performing, as a result of your chief problem. Please list and score ​at least 3 activities.

Activity 1.

2.

3.

4.

5.

Unable to perform activity

Unable to perform activity

Unable to perform activity

Unable to perform activity

Unable to perform activity

0 1 2 3 4 5 6 7 8 9 10

Able to perform activity at same level as before injury or problem

0 1 2 3 4 5 6 7 8 9 10

Able to perform activity at same level as before injury or problem

0 1 2 3 4 5 6 7 8 9 10

Able to perform activity at same level as before injury or problem

0 1 2 3 4 5 6 7 8 9 10

Able to perform activity at same level as before injury or problem

0 1 2 3 4 5 6 7 8 9 10

Able to perform activity at same level as before injury or problem

6

APT Intake Paperwork P3.pdf

You may receive bills from Diagonal Medical Billing.​. Payment Policy. I am ultimately responsible to pay the medical bill if my insurance company does not ...

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