Patient Information
Name:
DOB:
SS#
Address
Phone (H)
Phone (C)
Phone (W)
Marital Status
Married
Single
Divorced
Widowed
E-mail
Employer Name/ Adress
Referring Physician:
Phone #
Primary Care Physician:
Phone #
Body Part:
Injury:
Insurance Information
Primary Insurance
Policy #
Group #
Policy Holder:
DOB:
SS#
Phone Number
Secondary Insurance:
Policy #
Group #
Policy Holder:
DOB:
SS#
Phone Number
Authorization
Occupation:
Employer
Date of injury or onset:
Date of Surgery:
Type of Surgery:
Briefly describe your symptoms:
Test Results:
Symtoms Continued
Surgeries/Hospitalizations
Please list any recent/relevant surgeries or hospitilizations: (Please mark relevant date(s)
Packs per day
0-1
1-1.5
1.5-2
2-3
3+
No
Cigars/pipes per day
0-1
1-1.5
1.5-2
2-3
3+
No
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?
1-2 days/week
2-4 days/wweek
5+ days/week
Occasionaly
Never
What do your athletic/recreational activities entail?:
Lower Extremity Functional Scale
We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your
lower limb problem for which you are currently seeking attention. Please provide an answer for each activity.
Payment Policy and Procedures
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.
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
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.
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
Cancellation/No Show Policy/Late Policy
HIPAA Privacy Authorization
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.
ATTENDANCE POLICY
Time is valuable! Our treatment model provides one-on-one time with your therapist for every appointment. We understand that situations occasionally arise requiring you to cancel an appointment and will work with you to make schedule changes whenever possible. However, to allow us to provide individualized care to every patient, we have implemented the following cancellation policy.
Notice Requirement:
If you need to cancel or reschedule an appointment, please provide us with at least 24 hours' notice. This allows us to offer the time slot to another patient who needs care. Phone call, voice message and email are all acceptable forms of notification.
Cancellation Fee:
Appointments cancelled or rescheduled with less than 24 hours' notice will incur a $75 cancellation fee, unless able to be rescheduled for the same day. This fee covers the time reserved for your appointment and helps us maintain our scheduling efficiency. This fee is not billable to insurance and payment will be requested on your next visit.
If our office must cancel your appointment for any reason you may choose to meet with another available therapist on the same day, reschedule to another day, or cancel the appointment- you will not be charged.
Illness:
To maintain the health and safety of our staff and patients, the cancellation fee will be waived for acute illness. If you miss 2 consecutive visits due to illness, we may ask that you consult with your doctor before returning to PT.
Work Conflict:
Scheduling challenges due to work demands will be addressed by your therapist on an individual basis and should be discussed on your first visit.
No-Show Policy:
If you do not show up for your scheduled appointment or arrive more than 15 minutes past your appointment time without notifying us, you will be charged the full $75 fee. If you miss 2 appointments without contacting us, you will be discharged from our care. Communication is key to reaching your therapy goals!
Reminders:
As a courtesy to our patients, when requested we will provide calls or email reminders 1-2 days prior to scheduled appointments. Please note, we need current and correct contact information to provide this service, and the cancellation policy remains in effect even if you do not listen to or read your reminder message!
If you have any questions or need to cancel or reschedule your appointment, please contact our office at
410-828-6778 or [email protected] . We appreciate your understanding and cooperation in this matter.
I acknowledge I have read and understand the above cancellation policy.
Understanding Your First Visit
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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