New Patient Information

Insurance information

For patients injured on the job or involved in motor vehicle accidents, we will bill the insurance responsible for your coverage (Workers Compensation Company or Auto Insurance Company). Additionally, we request that you provide your private insurance information so that if your claim is denied or your PIP is exhausted, your private insurance can be billed. If your claim is denied and/or your PIP is exhausted, you will be responsible for the payment if you choose to not provide this information.
Injury related to:
Insurance Company Name *
Insurance ID number*
Subscriber's first name
Subscriber's last name
Subscriber's date of birth

MonthDayYear
Date
Insurance Group number
Insurance phone number ("Provider phone number")
(you may skip this if you took a picture of the front and back of your insurance card)

Secondary Insurance information

If you would like us to bill a secondary insurance, please complete this section. Otherwise you may skip ahead to the next section.
Insurance Company Name
Insurance ID number

For Worker's Comp and Auto Claims only
Claim Number (for worker's comp or auto claims only)
Date of Injury

MonthDayYear
Date
What state did the accident occur? (auto accidents only)

OregonWashingtonOther
Employer Name
Employer Phone number
HR phone number if available
Adjuster's Name (or local contact)

First NameLast Name
Adjuster's Phone Number

Area CodePhone Number
Local Contact's Phone Number

Area CodePhone Number
Do you have an attorney representing you for your current condition?*

YesNoOther
Attorney's Name
Attorney's Phone number
The following questions are for work-related injuries only

If your injury is not work-related, you may skip to the next page
Job title
Currently working
Work restrictions (if applicable)

Personal Information Release

Other than your insurance, doctor, or attorney, list person(s) allowed to receive your personal medical information.
P1: You may release my information to:

First NameLast Name
P1: Phone Number

Area CodePhone Number
P1: Relationship
P2: You may release my information to:

First NameLast Name
P2: Phone Number

Area CodePhone Number
P2: Relationship

Consent and signatures
Assigning Benefits*

I authorize my insurance company to make payment directly to the clinic. I give permission to send all necessary information about my claim and injury to my insurance company.Decline. If necessary or applicable, I will submit claims directly to my insurance for reimbursement.
Consent to treat*

I hereby consent to the provision of treatment by Armworks Hand Therapy.
Cancellations and no-shows*

I understand that failure to show and late-cancelled appointments jeopardize the ability of your clinics to provide appropriate care to the needs of patients and I will make every effort to give 24 hours notice prior to cancelling or rescheduling an appointment.
This is a fill in the blanks field. Please add appropriate blank fields and text.

NOTICE OF PRIVACY PRACTICES: THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

YOUR HEALTH INFORMATION
This notice applies to the information and records we have about your health and the health services you receive at this office. Your health information may include information created and received by this office. It may be in the form of written or electronic records or spoken words, and it may include information about your history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, related billing activity and similar types of health-related information. We are required by law to maintain the privacy of your protected information. We are required by law to give you this notice. It tells you how we may use and disclose your health information and describes your rights and our obligations regarding the use of that information. We will notify you should there ever be a breach of protected health information using the contact information you provide to us.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU We may use and disclose health information for the following reasons:

For Treatment. We may use your health information to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you and your health. For example, the doctor who referred you for therapy may be treating you for a medical or orthopedic condition and we may need to know about that or any other health problems that could complicate your treatment. We may use your medical history to decide what treatment is best for you. We will consult with your doctor and send reports about your treatment. We do this to provide the most appropriate care for you. Different personnel in our office may share information about you to people who do not work in our office to coordinate your care, such as telephoning your doctor and getting needed information. Family members and other health care providers may be part of your physical therapy outside this office and that may require us to provide information about you.

For Payment. We may need to disclose health information about you to bill your health plan or insurance company or other third party for your treatment in this clinic. We may also need to tell your health plan or insurance company about a treatment you are going to receive to obtain prior approval, or to
determine whether your plan will pay for the treatment.

For Health Care Operations. We may use and disclose health information about you to manage the clinic and ensure that you and other patients receive quality care. We may use your health information to evaluate the performance of our staff caring for you. We may also use health information about all or many of our patients to help use decide what additional services we should offer, how we can become more efficient, or whether certain treatments are effective for certain problems. We may also disclose your health information to your health plan and other health care providers that care for you to help these plans and providers evaluate or improve care, reduce cost, coordinate and manage health care and services, train staff and comply with the law.

Appointment Reminders We may contact you to remind you of your appointment.

Treatment Alternatives. We may tell you about or recommend possible treatment options or alternatives that may interest you.

Health-Related Products and Services. We may tell you about health-related products or services that may interest you. Please notify us if you do not wish to be contacted for appointment reminders, or if you do not wish to receive communications about treatment alternatives or health-related products and services. If you advise us in-writing that you do not wish to receive these communications, we will not use or disclose your information for these purposes.

OTHER CIRCUMSTANCES We may use or disclose health information about you for the following purposes, in accordance with the requirements and limitations of state and other law.

To Avert a Serious Threat to Health of Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Required by Law. We will disclose health information about you when required to do so by federal, state or local law.

Research. We may use and disclose health information about you for research projects subject to a special approval process. We will ask you for your
permission if the research will have access to your name, address or other information that reveals who you are, or will be involved in your care at the office.

Military, Veterans, National Security and Intelligence. If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs.

Public Health Risks. We may disclose health information about you for public health reasons to prevent or control disease, injury or disability; or report suspected abuse or neglect, non-accidental physical injuries or problems with products.

Health Oversight Activities. We may disclose to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in the response to a subpoena.

Law Enforcement. We may release health information if asked to do so by law enforcement officials in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.

Information Not Personally Identifiable. We may use health information about you in a way that does not personally identify you or reveal who you are.

Family and Friends. We may disclose health information about you to your family members or friends if we obtain your agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise and objection. We may also disclose this information if we can infer from the circumstances, based on our professional judgement that you would not object. For example, we may assume you agree for us to our disclosure to your spouse when you bring your spouse with you into the room during treatment or while treatment is discussed. In situations where you are not capable of giving consent (due to incapacity or medical emergency) we may, using our professional judgement, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the persons involvement in your care.

Non-Custodial Parent. We may disclose health information about a minor child equally to the custodial and non-custodial parent unless a court order limits the non-custodial parent’s access to the information.

OTHER USES AND DISCLOSURES PURSUANT TO YOUR SIGNED AUTHORIZATION: We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written authorization. Uses and disclosures requiring an authorization include:

Marketing. We may contact you, with consent, about a product/service we encourage you to purchase/consider in conjunction with your treatment.

Sale of Protected Health Information. We will not sell your health information for financial remuneration.

Fundraising Communications. We will not use your contact information for fundraising purposes.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy . You have the right to inspect and copy your health information, such as medical and billing records, that we keep and use to make decisions about your care. You must submit a written request to Jamie Mickalson to inspect and/or copy your health information. If you request a copy, we may charge a fee for the costs of copying, mailing or other associated supplies. We may deny your request to inspect and/or copy records in certain limited circumstances. If you are denied copies of or access to health information we keep about you, you may ask that our denial be reviewed. If the law gives you a right to have our denial reviewed, we will select a licensed health care professional to review your request and our denial. The personal conducting the review will not be the person who denied the request, and we will comply with the outcome of the review.

Right to Correct. If you believe your health information is incorrect or incomplete, you may ask us to amend the information. You have the right to request a correction if the information is kept by this office. To request a correction, complete and submit a MEDICAL RECORD AMENDMENT/ CORRECTION FORM to the Clinic's HIPAA Compliance Officer. We will provide you with this form at your request. We may deny your request for an amendment if your request is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to correct information that: (1) We did not create, unless the person or entity that created the information is no longer available to make the correction, (2) Is not part of the health information we keep, (3) You would not be permitted to inspect and copy, (4) Is inaccurate and incomplete

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a record of the disclosures we made of medical information about you for purposes other than treatment, payment, health care operations, and a limited number of exceptional circumstances involving national security, correctional institutions and law enforcement. The record may also exclude any disclosures we have made based on your written authorization. To obtain this accounting, you must submit your request in writing to Jamie Mickalson. It must state the period for which you want an accounting. The period may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the cost of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. You also have the right to request a limit on the health information we disclose to a health plan if the disclosure is for payment and the health information pertains solely to service you have paid us for in full. We are not required to agree to your request, except for requested restrictions on disclosures of information to your health plan where you have paid for the service in full. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or we are required by law to use or disclose the information. To request restrictions, you may complete and submit the REQUEST FOR RESTRICTION ON USE/DISCLOSURE OF MEDICAL INFORMATION AND/OR CONFIDENTIAL COMMUNICATION to the Clinic's HIPAA Compliance Officer. We will provide you with one of these forms at your request.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail or email. To request confidential communications, you may complete and submit the REQUEST FOR RESTRICTION ON USE/DISCLOSURE OF MEDICAL INFORMATION AND/OR CONFIDENTIAL COMMUNICATION to Clinic's HIPAA Compliance Officer. We will not ask you the reasons for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. To obtain such copy, contact the Clinic's HIPAA Compliance Officer.

CHANGES TO THIS NOTICE: We reserve the right to change this notice, and to make the revised or changed notice effective for medial information we already have about you as well as any information we receive in the future. We will post the current notice or a summary of the current notice in the office with its effective date in the top right-hand corner. You are entitled to a copy of the notice currently in effect.

COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact the Clinic's HIPAA Compliance Officer at (503) 491-1666. You will not be penalized for filing a complaint.

Effective Date: September 23, 2013
Thank you for reviewing our Patient Privacy Practices. A copy may be obtained on our website at https://www.sportscarept.com/patient-forms/*

I understand my privacy rights under HIPAA as stated on the Privacy Practices form

Financial Policy

NOTICE AND AGREEMENT

We are happy to have you as a new patient. As you know, your physician has determined occupational or physical therapy treatments are necessary and appropriate for your condition and has referred you to obtain services. We are glad you have selected our clinic for your care. In many cases, your insurance will pay for part or all of your care (Workers Comp patients, please see below).

We will work with you to ensure your insurance carrier, whether a medical care insurer or a motor vehicle accident insurer, receives all documentation needed to process and pay your claim. However, our relationship is with you as our patient and not with your insurance company. Because you are receiving the services, you have the final responsibility to pay for those services.

If your insurer fails to pay the full amount of our bill for services, after accounting for any applicable deductible amount, co-payment amount or hold-harmless amount, you will be required to pay the difference. Our bill is due in full when received. If you fail to pay in full and we are required to re-bill you after the 15th day of the month following the month you receive your bill, you may be charged a re-billing fee of $3.00 per month.

If you are receiving treatment as the result of a motor vehicle accident , you are responsible for paying all costs of treatment not reimbursed by the Personal injury Protection (PIP) coverage under a motor vehicle insurance policy or other insurance policy. If your motor vehicle accident claim is in dispute and there is no insurance coverage for your treatments, we may agree to accept regular monthly payments on your account. In this event, unpaid balances on your account will carry an overdue payment charge of $3.00 per month.

If you fail to make the agreed upon monthly payment, we may declare the entire amount of the bill due immediately. In some cases, your insurance company may issue payments directly to you. These checks must be endorsed and immediately forwarded to the billing office for processing. Please note that in the event you fail to make payment when due, this account will be referred to a collection agency for collection. In that event, a contingency fee of 40% will be added to the principal and interest due by the collection company. You will be additionally liable for attorney fees. Both collection agency fees and attorney fees will increase the balance you owe.

To Our Worker’s Compensation Patients :

We understand you have filed, or are in the process of filing, a claim for worker’s compensation insurance coverage for your injury and treatment.

If your claim is denied or if it is in dispute, we will bill your regular medical insurance carrier, pursuant to ORS 656.313, for the cost of your care, excluding any applicable deductible or copayment amounts. While your claim is in dispute, you are not required to pay any deductible or copayment to this clinic. Should your claim be in litigation and you later settle your claim and receive a dispute claim settlement, we require payment in full 10 days after disbursement. If your claim is later resolved against you, you are required to pay any deductible or co-payment not covered by your medical insurance.

If you do not have regular medical insurance, you are personally responsible for the cost of treatment. Please let us know if this is the case and we will make a special effort to accommodate your needs. Payments not received by the 15th of the month may be subject to a $3.00 per month re-billing fee. Please note that in the event you fail to make payment when due, this account will be referred to a collection agency for collection. In that event, a contingency feel of 40% will be added to the principal and interest due by the collection company. You will be additionally liable for attorney fees. Both collection agency fees and attorney fees will increase the balance you owe.
Our financial policy is also available on our website https://www.sportscarept.com/patient-forms/.*

I have reviewed the financial policy.

New Patient Information

Insurance information

Secondary Insurance information

For Worker's Comp and Auto Claims only

The following questions are for work-related injuries only

Personal Information Release

Consent and signatures

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