Digital Forms Page Low Back

Digital Form Submission

Welcome to our digital forms submission page. Please fill out the required fields below to provide essential information for your physical therapy session. Once completed, click ‘Submit’ to send your form directly to your physical therapist. Thank you for your cooperation!

Patient Information

Patient Information

Name:

DOB:

SS#

Address

Phone (H)

Phone (C)

Phone (W)

Sex

Marital Status

E-mail

Employer Name/ Adress

Referring Physician:

Phone #

Primary Care Physician:

Phone #

Body Part:

Injury:

Surgery:

Insurance Information

Primary Insurance

Policy #

Group #

Policy Holder:

DOB:

SS#

Phone Number

Secondary Insurance:

Policy #

Group #

Policy Holder:

DOB:

SS#

Phone Number

Authorization

I have reviewed the above information, other than any changes indicated above; I found the information to be correct. I have been informed of the coverage verified and understand that this is only a verbal verification of benefits, not guarantee of payment by my insurance company. This is not a guarantee of payment. We encourage you to independently verify you own insurance.

Occupation:

Employer

Date of injury or onset:

Date of Surgery:

Type of Surgery:

Briefly describe your symptoms:

Dominant Side:

Right Left

Involved Side:

Right Left

Test Results:

As the day progresses do symptoms:

Increase Decrease Stays the same

Do symptoms wake you at night?

Yes No

Symtoms Continued

Surgeries/Hospitalizations

Please list any recent/relevant surgeries or hospitilizations: (Please mark relevant date(s)

Do you smoke?

Packs per day

Cigars/pipes per day

Have you smoked in the past?

Year quit:

How many days per week do you consume alcoholic beverages?

How many drinks per day?

How often do you exercise?

What do your athletic/recreational activities entail?:

Accept Terms

By checking this box, you are acknoledging that the above information is true.

This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only ONE box, which applies to you. We realize you may consider that two of the statements in any one section relate to you, but please just mark the box, which MOST CLOSELY describes your problem.

Section 1 - Pain Intensity

I can tolerate the pain without having to use painkillers. The pain is bad but I can manage without taking painkillers. Painkillers give complete relief from pain. Painkillers give moderate relief from pain. Painkillers give very little relief from pain. Painkillers have no effect on the pain and I do not use them.

Section 2 -- Personal Care (Washing, Dressing, etc.)

I can look after myself normally without causing extra pain. I can look after myself normally but it causes extra pain. It is painful to look after myself and I am slow and careful. I need some help but manage most of my personal care. I need help every day in most aspects of self care. I do not get dressed, I wash with difficulty and stay in bed.

Section 3 – Lifting

I can lift heavy weights without extra pain. I can lift heavy weights but it gives extra pain. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, for example on a table. Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. I can lift very light weights. I cannot lift or carry anything at all.

Section 4 – Walking

Pain does not prevent me from walking any distance. Pain prevents me from walking more than one mile. Pain prevents me from walking more than one-half mile. Pain prevents me from walking more than one-quarter mile I can only walk using a stick or crutches. I am in bed most of the time and have to crawl to the toilet.

Section 5 -- Sitting

I can sit in any chair as long as I like I can only sit in my favorite chair as long as I like Pain prevents me from sitting more than one hour. Pain prevents me from sitting more than 30 minutes. Pain prevents me from sitting more than 10 minutes. Pain prevents me from sitting almost all the time.

Section 6 – Standing

I can stand as long as I want without extra pain. I can stand as long as I want but it gives extra pain. Pain prevents me from standing more than 1 hour. Pain prevents me from standing more than 30 minutes. Pain prevents me from standing more than 10 minutes. Pain prevents me from standing at all.

Section 7 -- Sleeping

Pain does not prevent me from sleeping well. I can sleep well only by using tablets. Even when I take tablets I have less than 6 hours sleep. Even when I take tablets I have less than 4 hours sleep. Even when I take tablets I have less than 2 hours sleep. Pain prevents me from sleeping at all.

Section 8 – Social Life

My social life is normal and gives me no extra pain. My social life is normal but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. dancing. Pain has restricted my social life and I do not go out as often. Pain has restricted my social life to my home. I have no social life because of pain.

Section 9 – Traveling

I can travel anywhere without extra pain. I can travel anywhere but it gives me extra pain. Pain is bad but I manage journeys over 2 hours. Pain is bad but I manage journeys less than 1 hour. Pain restricts me to short necessary journeys under 30 minutes. Pain prevents me from traveling except to the doctor or hospital.

Section 10 – Changing Degree of Pain

My pain is rapidly getting better. My pain fluctuates but overall is definitely getting better. My pain seems to be getting better but improvement is slow at the present. My pain is neither getting better nor worse. My pain is gradually worsening. My pain is rapidly worsening.

Please read carefully before you sign. Your signature acknowledges understanding of items set forth herein. If you have questions regarding any sections, please ask our staff for assistance.

Payment Policy and Procedures

I consent to the procedures, which may be performed during the duration of care at Optimum Performance Physical Therapy, LLC. I understand that if I fail to carry out the follow-up medical care, I do so at my own risk. I also understand that the rehabilitation process, by its very nature, involves certain inherent and unavoidable risks, including falls, and other similar injuries, and the only alternative to entirely avoid these risks would be to forego rehabilitation altogether. I understand that I have been referred for rehabilitative treatment and care to Optimum Performance Physical Therapy, LLC. Optimum Performance Physical Therapy, LLC has described my individual treatment plan. I understand that I have the right to have any questions answered prior to receiving any treatment, including any risks or alternative treatment plan that has been prescribed by my physician and or recommended by my therapist.

Release of Information

I give permission to OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC, to release information, verbal and written, contained in my medical record, and other related information, to my insurance company, rehab nurse, case manager, attorney, employer and/or related healthcare provider, assignees and/or beneficiaries and all other related persons as it relates to my treatment. I authorize OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC to obtain medical records and/or professional information from my physician and other medical professionals as it relates to my treatment.

Consent to Medical and Therapeutic Services

Financial Agreement/ Guarantee of Payment and Assignment of Benefits

Financial Agreement/ Guarantee of Payment and Assignment of Benefits: I request that payment of authorized insurance company(s), attorney, or legal representative, be made on my behalf to OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC. I authorize, OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC, if it chooses, to pursue on my behalf any appeals of the denial of my insurance benefits, and to release my medical records as required to determine benefits payable. OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC, its agents, and employees are hereby released from any and all liability of any nature that may arise from the release of information. I guarantee the payment of the full and entire allowed amount of all bills for services rendered for the patient. Any self-pay amounts not paid within forty-five (45) days of any notice of non-payment shall be subject to progressive collection activities up to and including referral to an independent collection agency or attorney for legal action, plus attorney fees up to 33 1/3% additional and court costs. I also understand that all insurance coverage quoted to me and /or responsible parties are estimated, and final determination of benefits and coverage lies with my insurance company. I certify that I have disclosed all health coverage information and I agree to provide OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC, with any changes in my insurance coverage in a timely manner. I understand that as a courtesy and based on the information I provide, OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC, will attempt to verify my insurance benefits. I understand that verification is never a guarantee of payment. I am responsible for payment of all co-pays and coinsurance estimates at the time of service and that these estimates may be higher than those for my primary care physician. Once my insurance company has processed claims, if the amount collected at the time of service was not enough to cover my portion, I may be billed in addition to cover my portion. Likewise, if the estimate I paid was more than my portion, I may be entitled to a refund. After 90 days of billing any secondary payer, unpaid coinsurance may become my responsibility.

Managed Care Plan Obligations

I understand that my insurance carrier may require me to have a current and complete written referral from my primary care physician. I understand that OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC, recommends I check with my carrier directly. If a referral is required and is not presented prior to my treatment being rendered, my insurance may not cover all or a portion of the medical expenses incurred. In this instance, I am responsible for all uncovered charges. It is my responsibility to assist OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC in obtaining additional referrals when necessary and appropriate. Should I require additional or more specific information regarding my insurance coverage, I will contact my carrier directly.

Cancellation/No Show Policy/Late Policy

It is our desire at OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC to provide every patient with the highest quality of care and services in a timely manner. Therefore, we provide a reserved time slot for each patient so there is minimal waiting, and each patient receives individual care. In order to continue with this high-quality service, we ask that you call at least 24 hours in advance if you are unable to keep your scheduled appointment. Missed appointments or greater than 15 minutes late without notifying staff, may result in a $75 no show/cancellation fee. Furthermore, additional scheduled visits may be automatically cancelled. We understand that personal schedules can be hectic, but to accommodate the needs of all our patients, we must maintain some level of accountability. Missed appointments on your part do not allow for continuity of care and affects your ability to reach the goals set by you and your physical therapist. Thank you for your consideration, our staff and other patients who may need your appointment time

HIPAA Privacy Authorization

I give OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC, permission to share my information with: (check 1 of the below 3 boxes)

Any member of my family

These Individuals: (list in box below)

Do not speak or share any of my information with family or friends, unless I give written/verbal permission

Your information may be sent to healthcare providers, health insurance companies protected by the federal privacy regulations, and to the individual(s) of your choice.

Your information may be transferred or utilized between the administration and professional staff • Transferred from OPPT to the billing contractor who handles our billing. They have signed an agreement not to utilize your records other than those necessary to administer your insurance claim and pervade internal reports to OPTIMUM PERFORMANCE PHYSICAL THERAPY, LLC.

You may refuse to sign this authorization and it will not affect your ability to obtain treatment. You may receive a copy of this authorization at the time of signing and/or revoke this authorization at any time by sending a written notificati0on to the office

I accept

Cancellation Policy

We take great pride in the time and service we provide our patients. We know your time is valuable and we are dedicated to providing you a thorough, comprehensive treatment at each and every visit. You will always be served with the highest level of respect, integrity and in the most cost-effective manner. We would appreciate your consideration as well. Patient cancellations and missed appointments are inevitable. In the event you are going to be late or cannot attend your appointment, please call Optimum Performance Physical Therapy at 410-828-OPPT (6778) to notify our staff. Failure to notify staff may result in a $75.00 cancellation/no show fee less than 24 hour notice.

Insurance

We participate with most insurance plans. Ultimately, it is your responsibility to know and understand the terms of your insurance coverage. Your insurance plan is a contract between you and your carrier. It is your responsibility to know whether your insurance carrier requires a referral or script. In the event that you arrive without a referral when one is required, you will be responsible for the bill or your visit will be rescheduled. We will verify benefits for Physical Therapy and help you understand your coverage. Please remember however, that benefits are not a guarantee of coverage or payment.

Co-Payment

This is a fixed amount set by your insurance company, which you are obligated to pay at the time of service. If your co-pay becomes a burden, please let us know. Legally we cannot waive your co-pay, but we can offer payment plans. Our main goal is to optimize your quality of life.

Co-Insurance

This is your cost share, usually calculated as a percentage of the cost of the service. Each plan and coverage is different. Please check with your insurance company.

Deductible

This is the amount you are responsible for before your insurance plan starts paying for services. Deductibles may not apply to all services. Please check with your insurance company.

Home Exercises

During your time at Optimum Performance Physical Therapy, LLC, we will prescribe exercises to be completed at home. These are individually designed to focus on your biggest limitations. It is important to complete the exercises as prescribed to make gains in range of motion, strength, and function. Failure to comply with the exercise recommendations prescribed to you can adversely affect your recovery. Please make your home exercise program a top priority. We want the best for you and your health. Your active participation and diligence will help us help YOU!

If you have questions or concerns, contact us at 410-828-OPPT (6778) or www.oppt.biz. We look forward to working with you!

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