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.
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
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.
Cancellation Policy
Insurance
Co-Payment
Co-Insurance
Deductible
Home Exercises
If you have questions or concerns, contact us at 410-828-OPPT (6778) or www.oppt.biz.
We look forward to working with you!
Send
