New Patient Intake Forms

Patient Forms
Which clinic are you visiting?*

StevensvilleMissoulaMissoula at the Family YMCA

Authorization for Release of Medical Records

to Valley Physical Therapy: Missoula Clinics (406) 721-3956—Stevensville Clinic (406) 777-7042
Physician:
Fax Number:
Please enter a valid phone number.
Complaint:
Accident Related to Work?

NoYes
Authorization:

I hereby authorize the above Physician to release all information regarding Prescriptions, Office Notes, X-Ray Report(s), MRI Report(s), and OP Report(s) to Valley Physical Therapy.
Patient or Guardian Name:

First NameLast Name
Date

MonthDayYear
Signature

Clear

Patient Demographics/Insurance
Name:*

First NameLast Name
DOB:*

MonthDayYear
Age:
SSN:
Guardian (if patient is a minor):

First NameLast Name
Physical Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address the same as your physical address?*

YesNo
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number:*
Please enter a valid phone number.
Cell Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Emergency Contact:*

First NameLast Name
Phone Number:*
Please enter a valid phone number.
Relationship:*
Employer:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Occupation:
Primary Insurance:
Policy Holder's DOB:

MonthDayYear
Policy Holder's Name:

First NameMILast Name
Policy #
Group #
Secondary Insurance:
Policy Holder's DOB:

MonthDayYear
Policy Holder's Name:

First NameMILast Name
Policy #
Group #
Worker's Compensation Carrier:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Adjustor:
Nurse Case Manager:
Claim Number:
Date of Injury:

MonthDayYear

Clinic Policies
Please review our clinic policy.

Payment:

Self-Pay: Payment is required at time of services rendered unless prior arrangements have been made in writing.

Private Insurance/Motor Vehicle Insurances: We expect payment for the initial visit. We will bill your insurance company if all the necessary information is provided. We expect regular payments of charges not covered by your insurance company. We will provide you with copies of all charges and services once a month. A signed payment agreement may be established with our Billing Coordinator. Any overpayments will be promptly refunded.

Worker’s Compensation: If your claim is denied by WC, you will be responsible for any treatments rendered. We will bill your personal health insurance carrier for you and/or set up payment arrangements. I understand Valley Physical Therapy notifies my insurance carrier of canceled or no show appointments.

Medicaid: You will be responsible for treatment rendered for which we do not have authorization. Please present your current card the first visit of each month you are being treated. Co-payments are due at time of treatment.

Past Due Accounts: A 1.0% Finance Charge will be assessed for accounts 60 days past due. If payment is not made on accounts 90 days past due, the account will be referred to a collection agency.

Authorization to Pay Benefits: I hereby authorize my insurance benefits be paid directly to Valley Physical Therapy and I am financially responsible for services. I am responsible for payment of my account even though I have filed an insurance claim.

Release of Information: I hereby authorize Valley Physical Therapy to release any information to my treating physician, insurance company, worker’s compensation carriers, or attorneys.
Acknowledgement*

I have read and understand the above. Any changes to this clinic policy must be initiated by both parties.Cancellations/No Shows: Valley Physical Therapy reserves specific appointment times for your care. We recognize that sometimes life happens. If during the course of treatment you must cancel, please notify Valley Physical Therapy a minimum of 24 hours before your scheduled appointment time. Attending all of your physical therapy sessions is important to you reaching your desired outcomes. Consistently missing physical therapy appointments may result in prolonged recovery or failure to reach your goals.
Patient or Guardian Name:*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear

HIPAA Notice of Privacy Practices for Valley Physical Therapy

Effective Date: 4/14/2003

Collapse HIPAA Policy
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.

If you have any questions about this notice, please contact Gayle Croft.

Who Will Follow This Notice:

This notice describes our office’s practices and that of:
- Any health care professional authorized to enter information into your chart.
- All employees, staff, and other VPT personnel.
- Valley Physical Therapy (VPT) in Missoula, VPT at The Women’s Club, and VPT in Stevensville. All these entities, sites, and locations follow the terms of this notice. In addition, these entities, sites, and locations may share medical information with each other for treatment, payment, or practice operations purposes described in this notice.
  
  Our Pledge Regarding Medical Information:
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at this office. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the office, whether made by office personnel or your therapist. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

make sure that medical information that identifies you is kept private;
give you this notice of our legal duties and privacy practices with respect to medical information about you; and
follow the terms of the notice that is currently in effect.

How We May Use and Disclose Medical Information About You

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to your doctors, nurses, technicians, and medical students. We also may tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Payment. We may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about referral source and treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:
- to prevent or control disease, injury, or disability;
- to report child abuse or neglect;
- to report reactions to medications or problems with products;
- to notify people of recalls of products they may be using;
- to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
- to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.
We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigators, inspections, and licensors. These activities are necessary for the government 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 medical information about you in a response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
- In response to a court order, subpoena, warrant, summons or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at the hospital; and
- In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description, or location of the person who committed the crime.
Coroners, Medical Examiners, and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities. We may release medical information about you to authorized officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons of foreign heads of state or conduct special investigation.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

To request restrictions, you must make your request in writing to Gayle Croft. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communication. 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.

To request confidential communications, you must make your request in writing to Gayle Croft. We will not ask you the reason 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.

Changes to this Notice:

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the clinic. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register at the office, for treatment or health care services, we will offer you a copy of the current notice 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 to VPT, contact Gayle Croft, Administrative Assistant (406-721-3096). All complaints must be submitted in writing to Valley Physical Therapy, 1001 SW Higgins, Ste 205, Missoula, MT 59803.

You will not be penalized for filing a complaint.

Other Uses of Medical Information:

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer disclose information about you for the reasons covered by your written authorization.

You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.

Acknowledgement of Receipt of Notice of Privacy Practices
By signing this form, you acknowledge that Valley Physical Therapy has offered or given you a copy of its Notice of Privacy Practices. This notice explains how your health information will be handled. HIPAA, the new Federal law concerning medical privacy, requires this notice.

I have been offered or received a copy of the Notice of Privacy Practices. Valley Physical Therapy has given me the opportunity to ask any questions about this notice and all my questions have been answered.
Patient or Guardian Name:*

First NameLast Name
Signature:*

Clear
Date:*

MonthDayYear
Please verify that you are human*
Should be Empty:

	0 None	1	2 Mild Annoying	3	4 Nagging Uncomfortable	5	6 Miserable Distressing	7	8 Intense Horrible	9	10 Unbearable
Best
Worst
Current

	Yes	No
Alzheimers
Heart
Lung
Stroke
Current Infection
Diabetes (type 1/type2)
Smoking
Fibromyalgia
High/Low Bp
Cancer
Immunosuppression

	Yes	No
Auto Immune Disorder
Neurological Disorder
Incontinence
Hearing/Vision Loss
Osteoarthritis
Rheumatoid Arthritis
Mental Health
Balance Loss
Dizziness/Vertigo
Osteoporosis

Patient Forms

Authorization for Release of Medical Records

Patient Demographics/Insurance

Patient Information

Please list 3 activities you would like to improve with physical therapy rating 0-10 where 0 is NO LIMITATION WITH ACTIVITY and 10 is MAXIMUM LIMITATIONS/CAN'T PERFORM.

Clinic Policies

HIPAA Notice of Privacy Practices for Valley Physical Therapy

Acknowledgement of Receipt of Notice of Privacy Practices