Welcome Letter and Attendance Policy - Physical Therapy

Welcome Letter and Attendance Policy

Welcome to P.T. Services Rehabilitation, Inc., your local physical therapy provider. On your first visit, a treatment plan will be set up, and goals established to help measure your progress. This plan of care will be sent to your referring physician. As your treatment progresses, please inform us of your next doctor's appointment so that we can accurately communicate your progress and attendance to the doctor.

Typically, your frequency of visits will be 1-3 times per week and will last approximately 45 to 60 minutes per session. This is determined by the therapy you are receiving and the coverage by your insurance. Please schedule and confirm your appointments with the front desk staff as you leave therapy. If you must cancel an appointment, please call the office and reschedule another appointment at that time.

Your attendance at therapy is crucial to successfully achieving your goals. Your attendance will be reported to your physician on our plan of care updates. You will be subject to discharge from treatment if you:

? Miss 3 consecutive visits without a phone call to cancel ? Are not seen for therapy in 30 consecutive days ? Have an attendance of less than 50% over the course of 1 month Please note: If you are more than 10 minutes late for your appointment, you may not receive your full treatment, as we have to keep scheduled appointments with our patients. We typically give home exercises and instructions which you are expected to complete. As the old saying goes, "Practice makes perfect." And this is especially true for therapy. We are please to work with you toward your therapy goals. Thank you.

I, , understand the above attendance policy.

Date:

Patient/Caregiver signature:

CONSENT TO USE ANSWERING MACHINE/VOICE MAIL TO COMMUNICATE WITH PATIENT

The undersigned hereby authorizes P.T. Services Rehabilitation, Inc. and its employees and agents, to leave voice mail messages regarding my treatment at the following

Phone number:

I understand that by signing this release, I expressly consent to allowing P.T. Services Rehabilitation, Inc., to convey confidential and sensitive information regarding my care and treatment over a voice mail system. It is my express desire that such messages be left on my voice mail system in my absence to expedite communication regarding my care and treatment. I hereby release P.T. Services Rehabilitation, Inc., and its employees and agents, from any liability associated with leaving such messages on the voice mail at the telephone number set forth above.

CONSENT TO NOTIFY

The undersigned hereby authorizes P.T. Services Rehabilitation, Inc. and its employees and agents, to notify the designated person below regarding my treatment and/or in case of emergency:

NameHome Phone #

AddressCityStateZip

EmployerWork Phone #

I understand that by signing this release, I expressly consent to allowing P.T. Services Rehabilitation, Inc., to convey confidential and sensitive information regarding my care and treatment to the above named person. I hereby release P.T. Services Rehabilitation, Inc. and its employees and agents, from any liability associated with leaving such messages with this person set forth above.

SignatureDate

RESTRICTED NOTIFICATION

Please list the individuals that you do not want to receive any information regarding your care and treatment communicated by any means.

This authorization is valid until such time as the patient revokes it.

P.T. Services Rehabilitation, Inc. PATIENT HISTORY

Patient to complete the following questions:

1. When did this problem begin? _____ Was it caused by a specific incident? Yes No

If yes, please explain__________________________________________________________________

__________________________________________________________________________________

If No, what do you think may be causing this problem?_______________________________________

__________________________________________________________________________________

2. What types of activities or postures aggravate your symptoms?____________________________________

______________________________________________________________________________________

3. What types of activities or postures relieve your symptoms?_______________________________________

______________________________________________________________________________________

4. When did you last see your doctor? ______________ When is your next appointment?_________________

5. Have you had any special tests to determine the cause of your problem (X-Rays, blood work, MRI, etc.)

Yes - please specify _________________________________________________

No

6. Are more tests being planned? Yes No Explain__________________________________________

7. Have you undergone surgery for this problem? Yes No If yes, when? _________________________

8. What medications are you currently taking?____________________________________________________

9. Do you have any medication or skin allergies? _________________________________________________

10. Have you had this problem or similar pain before? Yes No If yes, when? _____________________ What treatment did you receive?___________________________________________________________ Results:_______________________________________________________________________________

11. Have you received Physical, Occupational or Speech therapy in the past twelve months for this condition? Yes No Explain___________________________________________________________________ Results___________________________________________________________________

12. Please check if you have had or currently have, any of the following medical conditions:

___ Broken Bones ___ Trauma ___ Metal Implants ___ Arthritis

___ Diabetes ___ Heart Disease ___ Pacemaker Implant ___ Circulatory Problems ___ High Blood Pressure

___ Cancer ___ Unexplained Weight Loss ___ Kidney Disease ___ Liver Disease ___ Infectious Disease ___ Lung Disease

___ Neurological Problems ___ Stroke ___ Migraine Headaches ___ Bowel / Bladder Control ___ Psychological ___ Seizures

Prior surgeries._________________________________________________________________________

13. Please list any recent hospitalizations / reasons/ dates: _________________________________________

14. Females: Is there a chance you may be pregnant at this time? Yes No

15. Are you currently working? Yes No If yes, are you under restrictions? Yes No

If yes, Please explain:_________________________________

_____________________________________________________________________________________

If you are not working, is it because of this problem? Yes No

How long have you been off work or on restrictions?____________________________________________

Do you have a target date set for return to work or getting off the restrictions? Yes No

Date______________

16. What is your occupation? ________________________ What are your job duties? ___________________

_____________________________________________________________________________________

17. What are your goals for therapy?___________________________________________________________

Patient Signature: Date PT/OTR Signature: Date

PATIENT INFORMATION

PLEASE PRINT CLEARLY

DATE: ____________

PATIENT NAME: LAST ________________________________FIRST ______________________________MI ________

ADDRESS: STREET ____________________________________________________________ P.O. BOX ____________

CITY ___________________________ STATE _____________ ZIP ___________ PHONE (______) ______-_________

CELL PHONE (____) _____-_________

SSN#: ______-_____-_______ DATE OF BIRTH: ____/____/____ FEMALE _____ MALE ______ RACE______

EMAIL ADDRESS_____________________________________________________________________________________

STATUS: (CIRCLE ONE) 1. SINGLE 2. MARRIED 3. DIVORCED 4. WIDOWED 5. SEPARATED

GUARANTOR /RESPONSIBLE PARTY: _______________________________ RELATIONSHIP: __________________

ADDRESS: ________________________________________________________ PHONE: (______) ______-__________

EMPLOYMENT INFORMATION

EMPLOYER: _____________________________________________ OCCUPATION: ____________________________

ADDRESS: STREET _____________________________________________ WORK FAX # (______) ______-_______

CITY __________________________ STATE _________ ZIP __________ WORK PHONE (______) ______-_______

EMERGENCY CONTACT INFORMATION

NAME: LAST ________________________________________ MI _____ FIRST ________________________________

PHONE: (______) ______-__________

RELATIONSHIP: ____________________________________

PHYSICIAN INFORMATION

PRIMARY PHYSICIAN: _________________________________________ PHONE: (______) ______-__________

REFERRING PHYSICIAN: _______________________________________ PHONE: (______) ______-__________

INJURY INFORMATION

DATE OF INJURY: ____/_____/______ EMPLOYMENT RELATED? YES NO

W/C CLAIM? YES NO

HAVE YOU RECEIVED THERAPY/CHIROPRACTIC SERVICES IN THE PAST 12 MONTHS? YES NO

ARE YOU RECEIVING HOME CARE SERVICES? YES NO NAME OF AGENCY: _________________________

HAVE YOU BEEN A PATIENT HERE BEFORE? YES NO IF NO, HOW DID YOU FIND OUT ABOUT US?

AUTO ACCIDENT? YES NO

POST OPERATIVE? YES NO

INSURANCE INFORMATION

PRIMARY: ________________________________ INSURED ID #: COPY CARD S.S.#______-_______-__________ NAME OF INSURED: _____________________________________ INSURED'S DATE OF BIRTH: _____/_____/_____ INSURED'S EMPLOYER: _________________________ RELATIONSHIP TO INSURED:________________________

SECONDARY: _____________________________ INSURED ID #: COPY CARD NAME OF INSURED: _____________________________________ INSURED'S DATE OF BIRTH: _____/_____/_____ INSURED'S EMPLOYER: _________________________ RELATIONSHIP TO INSURED:________________________

FINANCIAL AGREEMENTS For and in consideration of services rendered or to be rendered to the above named patient by P.T. Services, Rehabilitation Inc. I agree, whether acting as an agent or patient, to pay the amount due this facility. I will make current payments as bills are rendered or I will assign my insurance benefits for direct payment to this facility, and I will pay copay amounts at the time service is provided and any uncovered differences upon receipt of a statement. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure payment.

SIGNED: __________________________________________________________ DATE: __________________________ WITNESS: _________________________________________________________ DATE: __________________________

04/09

Notice of Privacy

I understand that as part of my healthcare, P.T. Services Rehabilitation Inc. originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment. A means of communication among the many health professionals who contribute to my care. A source of information for applying my diagnosis to my bill. A means by which a third-party payer may verify that services billed were actually provided. A tool for routine healthcare operations such as assessing quality and reviewing competency of

professionals. I understand that I am given this notice prior to signing consent, and P.T. Services Rehabilitation Inc. reserves the right to change their notice and practices upon a reasonable implementation and notification period. I understand that I have the right to object to the use of my health information, and I may restrict as to how my health information may be used or disclosed. However, P.T. Services Rehabilitation Services Inc. is not required to agree to the restriction requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.

In consideration of the statements above, please be advised that, P.T. Services Rehabilitation Inc. has a legal obligation to protect your health information by following appropriate privacy practices.

Please initial:_____ Date _________ (Parent or Guardian's initial's is required if patient is a minor)

Patient's comments or restrictions____________________________________________ Witness initial:_____ Date ______________________ __________________________________________________________________________________

Patient Consent Form

A) I hereby consent and authorize P.T. Services Rehabilitation Inc. to administer treatment as ordered by the physician and deemed necessary in the treatment of this patient.

Please initial:_____ Date _________ (Parent or Guardian's initial's is required if patient is a minor)

Patient's comments or restrictions: _______________________________________________ Witness initial:____ Date ______________________

B) I hereby consent and authorize P.T. Services Rehabilitation Inc. to use or disclose information pertaining to my health record for the purposes of: conducting appropriate rehabilitative treatment, seeking payment for services rendered, or performing required healthcare operations activities such as, but not limited to, medical chart reviews or case conferences.

Please initial:_____ Date _________ (Parent or Guardian's initial's required if patient is a minor)

Patient's comments or restrictions: _______________________________________________ Witness initial:____ Date __________

C) I expressly consent to allowing P.T. Services Rehabilitation Inc. to convey confidential Information of my care and treatment over voice mail system/answering machine in my home.

Please initial:____ Date:___________

Patient Signature: _______________________________ Date________________________

Patient's name (Parent or Guardian's signature is required if patient is a minor)

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