PLEASE DO NOT COMPLETE THE FOLLOWING SECTION ON FIRST VISIT
I acknowledge that I have reviewed the information listed and confirm that there are no changes to my demographic and insurance information.
Thank you for choosing Rock Valley and providing us the opportunity to work with you. We hope to exceed your expectations and assist you in achieving your goals.
Notice of Privacy Practices:I acknowledge being offered Rock Valley Physical Therapy’s Notice of Privacy Practices pamphlet. I have initialed here to indicate that I understand my rights through HIPAA and that I am declining this pamphlet.
Authorization to Release Information:I authorize the release of any medical or any other information to the Centers for Medicare and Medicaid Services (CMS), my insurance carrier(s), or other entities necessary to determine insurance benefits or the benefits payable for related medical services and /or supplies provided to me by Rock Valley Physical Therapy.
Financial Responsibility:I understand that insurance billing is a service provided as a courtesy and that I am, at all times, financially responsible to Rock Valley Physical Therapy. It is my responsibility to notify Rock Valley Physical Therapy of any changes in my health care insurance coverage. If the submitted charges or any part of them are denied for payment, I am responsible for the balance. I request that payment of my services be made on my behalf to Rock Valley Physical Therapy. I understand that by signing this form, I am accepting financial responsibility, as explained above, for payment of the balance of all medical services. I also understand that Rock Valley Physical Therapy collects for copayments at the time of service.
Supply Items:I understand that Rock Valley Physical Therapy may, during the course of treatment, recommend purchase of a supply item. Supply items may or may not be covered under my insurance plan. I understand that it is my financial responsibility to pay for any item in full if it is not covered under my insurance plan.
This is to verify that I have read and agree with the above.
Rock Valley Physical Therapy does not discriminate against any person on the basis of race, color, national origin, disability, or age in admission, treatment, or participation in its programs, services and activities, or in employment. For further information about this policy, contact the administrative assistant at (309)-743 2070. TDD/Relay Iowa.
Please complete a bladder log every day for 2 days and bring it to your appointment. Please do at least one day on a working day.
The main purpose of a bladder log is to document how your bladder functions. A log can give your health care provider an excellent picture of your bladder functions, habits and patterns. At first, the log is used as an evaluation tool. Later, it will be used to measure your progress on bladder retraining or leakage episodes.
Your log will be more accurate if you fill it out as you go through the day. It can be very difficult to remember at the end of the day exactly what happened in the morning.
INSTRUCTIONS:Column 1 – Time of DayThe log begins with midnight and covers a 24 hour period. Afternoon times are in bold. Select the hour block that corresponds with the time of day you are recording information.
Column 2 – Type & Amount of Fluid & Food Intake
Column 3 – Amount Voided (Urinated): Two methodsRecord the time of day and the amount voided. Use the first method unless directed by your health care provider to directly measure or count urine amounts. Record a bowel movement with a BM at theappropriate time.
Column 4 – Amount of LeakageRecord the amount of urine loss at the time it occurred.S – SMALL = drop or two of urineM - MEDIUM = wet underwearL – LARGE = wet outerwear or floor
Column 5 – Was Urge PresentDescribe the urge sensation you had as:1 – MILD = first sensation of need to go2 – MODERATE = stronger sensation or need3 – STRONG = need to get to a toilet, move aside!
Column 6 – Activity with LeakageDescribe the activity associated with the leakage, i.e. coughed, heard running water, sneezed, bent over,lifted something or had strong urge.
CommentsAt the bottom of the log table – Special problems and new or changes in medication are recorded here. Ifa pad change was needed, record the number used during the day at the bottom of the page.
*Download pdf for an example Daily Voiding Log.