Patient Intake Form

PATIENT INFORMATION FORM
Full Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Date of Birth *

MonthDayYear
Date
Emergency Contact Name*
Emergency Contact Phone Number*

Area CodePhone Number
Injury/Onset Date

MonthDayYear
Date
Body Part/Dx
Work Related:

YesNo
Auto Related:

YesNo
How Did You Hear About Us?*

MD referralWord of mouth/past patientOther
Name of Referring MD:
Medicare Only: Are you receiving Home Health Services?*

YesNo
If Yes, Name of Agency:
Discharge Date:

MonthDayYear
Date

Insurance Information
Insurance Plan: Primary*
Policy ID # *
Group #
Patient Relationship to Cardholder:*

SelfSpouseChild
Date of Birth of Subscriber:*

MonthDayYear
Date
Insurance Plan: Secondary
Policy ID #
Group #
Phone Number:

Area CodePhone Number
Patient Relationship to Cardholder:

SelfSpouseChild
Date of Birth of Subscriber:

MonthDayYear
Date

Protecting Your Medical Identity
Most people are aware of the risk of identity theft related to financial records, social security number, etc. As a recipient of health care services, you also need to be aware of the risk of other people using your identity to obtain medical services under your insurance coverage. Medical Identity Theft is a real risk in our society and the consequences can be very serious. For example, if a person uses your identity to obtain services, your medical record may be compromised by the other person receiving treatment for illnesses that would be contradictory to your health history.

Due to these risks, we take precautions to help protect your medical identity. This includes requiring our admissions staff to require that you show a photo identification at the point of admission or at the point of your first visit. Please be understanding of our staff when they ask you for ID, as it is part of the processes to help protect your Medical identity.

You should also be proactive in guarding and protecting your insurance card number, Medicare number, and Social Security number.

You should be aware and watch for the following Red Flags as possible signs of Medical Identity Theft. If you become aware of any of these areas of concern, please let us know so we can assist you in making any necessary corrections and notifications of appropriate government agencies. If you prefer, we also encourage you to contact the Federal Trade Commission at 877-FTC-HELP to report any issues.

You receive a bill or a notice of insurance benefits (Explanation of Benefits EOB) for services you did not receive.

You receive a collection notice from a bill collector for a bill that you think does not relate to services you received.

Your insurance company notifies you that coverage for legitimate hospital stays is denied because insurance benefits have been depleted or a lifetime cap has been reached.

You notice information added to your credit report by a health care provider or insurer.

You receive an inquiry from an insurance fraud investigator or a law enforcement agency.

If you have any questions related to Medical Identity Theft, you may call our office at 919 769 0002.
HIPPA Privacy Policy
It is the policy of Physical Therapy Partners, LLC, that all providers and staff preserve the integrity and the confidentiality of protected health information (PHI) pertaining to our patients. The purpose of this policy is to ensure that our practice and its providers and staff have the necessary medical and PHI to provide the highest quality physical therapy care possible while protecting the confidentiality of the PHI of our patients to the highest degree possible. Patients should be confident to provide information to our practice and its providers and staff for purposes of treatment, payment and healthcare operations (TPO), knowing that our practice and its providers and staff will adhere to the standards set forth in the Notice of Privacy Practices.

Collect, use and disclose PHI only in conformance with state and federal laws and current patient covenants and/or authorizations, as appropriate. Our practice and its providers and staff will not use or disclose PHI for uses outside of practice's TPO, such as marketing, employment, life insurance applications, etc. without an authorization from the patient. Use and disclose PHI to remind patients of their appointments only with their consent.

Recognize that PHI collected about patients must be accurate, timely, complete, and available when needed. Our practice and its providers and staff will:

Implement reasonable measures to protect the integrity of all PHI maintained about patients.

Recognize that patients have a right to privacy. Our practice and its providers and staff respect the patient's individual dignity at all times. Our practice and its providers and staff will respect patient's privacy to the extent consistent with providing the highest quality medical care possible and with the efficient administration of the facility.

Act as responsible information stewards and treat all PHI as sensitive and confidential. Consequently, our practice and its providers and staff will: Treat all PHI data as confidential in accordance with professional ethics, accreditation standards, and legal requirements.

Not disclose PHI data unless the patient for his or her authorized representative) has properly consented to or authorized the release or the release is otherwise authorized by law.

Recognize that, although our practice "owns" the medical record, the patient has a right to inspect and obtain a copy of his/her PHI. In addition, patients have a right to request an amendment to his/her medical record if he/she believes his/her information is inaccurate or incomplete. Our practice and its providers and staff will-- Permit patients access to their medical records when their written requests are approved by our practice. If we deny their request, then we must inform the patients that they may request a review of our denial. In such cases, we will have an on-site healthcare professional review the patients' appeals.

Provide patients an opportunity to request the correction of inaccurate or incomplete PHl in their medical records in accordance with the law and professional standards. All providers and staff of our practice will maintain a list of all disclosures of PHI for purposes other than TPO for each patient. We will provide this list to patients upon request, so long as their requests are in writing.

All providers and staff of our practice will adhere to any restrictions concerning the use or disclosure of PHI that patients have requested and have been approved by our practice.

All providers and staff of our practice must adhere to this policy. Our practice will not tolerate violations of this policy.

Violation of this policy is grounds for disciplinary action, up to and including termination of employment and criminal or professional sanctions in accordance with our practice's personnel rules and regulations.

Patient Consent Form
I hereby consent to the evaluation and treatment of my condition by a licensed Physical Therapist. I understand that I will be receiving an Initial evaluation followed by treatment sessions to address my condition.

These sessions may include one or more of the following: Joint mobilization, or manipulation, soft tissue work, manual therapy, electrical stimulation, heat/ice, mechanical or manual traction, passive/active range of motion, strengthening exercises, therapeutic exercises/activities, stretching exercises, dry needling and a home exercise program.
Please Type Your Initials: Initials*
Assignment of Benefits and Insurance Proceeds
I hereby authorize payment from my insurance company of medical benefits for services rendered by Physical therapy Partners, LLC by an assignment of benefits. The completion of insurance forms and the assignment of insurance benefits do not relieve the undersigned of the obligation to pay the amount owed for Physical Therapy services.
Please Type Your Initials: Initials*
Release of Information
I hereby authorize release of information necessary to file claims with my insurance company and information to my physicians. I permit a copy of this authorization to be used in place of the original.
Please Type Your Initials: Initials*
Receipt of Privacy Practice/Protecting your identity

I have received a copy of Physical Therapy Partners, LLC notice of privacy practices and protecting your identity and have had an opportunity to ask questions.
Please Type Your Initials: Initials*
Confirmation of Consent

Please sign inside the below box by dragging your mouse inside the square and pressing down the button while signing on a desktop or by using your finger on a mobile phone.
Signature

Clear
Date*

MonthDayYear
Date
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PATIENT INFORMATION FORM

Insurance Information

Medical History

Protecting Your Medical Identity

HIPPA Privacy Policy

Patient Consent Form

Assignment of Benefits and Insurance Proceeds

Release of Information