Partners in Physical Therapy
3221 Ryan Street, Suite D, Lake Charles, LA 70601
Patient’s Name: ______Date of Birth: ______
Address: ______
City: ______State: ______Zip: ______
Home Phone: ______Work Phone: ______
Cell Phone: ______Email: ______
Social Security #: ______Sex: M F Marital Status: S M D W
Employer: ______Whom may we thank for referring you? ______
Circle: /Auto Accident/Employment related/Post-Op/Other Accident Date:______
Responsible Party (Same as above? Yes No)
Name: ______Date of Birth: ______
Address: ______Social: ______
City: ______State: ______Zip: ______
Is this an Attorney or WC Case Manager? Yes No Phone: ______Fax: ______
Emergency Contact
Name: ______Relationship: ______
Home Phone: ______Other: ______
No Show/ Cancellation Policy
I have been informed and understand that I must call to cancel my appointments prior to the start time. If I do not, there will be a $25 FEE. This fee must be paid to the start of the next appointment. In addition, THREE MISSED appointments in a row will result in the cancellation of future appointments and a letter forwarded to my primary referral source. I have also been informed that Workers Compensation and Personal Injury patients will have cancelled or missed appointments documented and forwarded to the case manager/attorney. I understand that I am responsible for any payments not covered by my insurance, attorney or workers compensation, including co-payments and annual deductibles.
Patient/Guardian: ______Date: ______
Partners in Physical Therapy will communicate your treatment with your physicians in compliance with Hippa Privacy Act. We need your permission to release your information to any other individuals.
I authorize Partners in Physical Therapy to release and/or discuss any and all personal and clinical information to my treatment at this facility to:
(Example: Spouse, Family Members, Friends, Etc.)
______
Name (Primary Contact) Relationship Telephone #
______
Name (Secondary Contact) Relationship Telephone #
May we call your home to set up future appointments? Yes No
May we leave a message with someone at your home or on your
answering machine? Yes No
May we call you by your name in the clinic when calling you back
for your appointment or while you are in the back of the gym? Yes No
You will be in contact with others in the gym part of our facility.
Do we have your permission to treat you and give you instructions
while others are in the gym? Yes No
Can your medical folder be in plain view of others with your name
on it? (your folder will be closed at all times so no information
can be seen) Yes No
There are times within the course of treatment when your treatment
room door will be left open or partially open. Is this okay with you?
(you may request at any time your door to be closed) Yes No
______
Patient Signature Date
I understand that as part of my health care treatment, Partners in Physical Therapy develops and maintains records containing my health information, which includes information about my health history, symptoms, test results, diagnosis, treatment, claims and payment information, etc. I understand that my health information will be used and disclosed by Partners in Physical Therapy for treatment, payment and health care operations and serves as:
§ A basis for planning my care and treatment
§ A means of communication among health professionals who may contribute to my care
§ A source of information to bill for health care services rendered
§ A means by which an insurance company or other third party payor can verify that services were billed and actually provided
§ A resource for “health care operations” such as assessing quality and reviewing the competence of health care professionals
I have been provided with the Partners in Physical Therapy Privacy Notice, which provides a more complete description to the use and disclosure of my health information. I understand that I have the right to review the Privacy Notice prior to signing this consent form. I understand that Partners in Physical Therapy can change the terms of the Privacy Notice and that Partners in Physical Therapy reserves the right to make the new Privacy Notice provisions effective for my health information that it already maintains and uses, as well as for any health information that it may receive in the future.
I understand that if I refuse the sign this consent form allowing for the use and disclosure of my health information to carry out treatment, payment or health care operations, Partners in Physical Therapy may refuse treatment.
I understand that I have the right to request that Partners in Physical Therapy restrict how my health information is used or disclosed to carry out treatment, payment or health care operations, but such request may not be accepted. I request the following restrictions (N/A if none): ______
I understand that I may revoke this consent at any time by notifying Partners in Physical Therapy in writing, but if I do, it will not have any effect on uses or disclosures prior to the receipt of the revocation.
I give my consent to Partners in Physical Therapy to release my medical records to my referring physician, insurance company, third party insurance, or to my attorney.
I authorize my insurance company to pay directly to Partners in Physical Therapy proceeds payable under the terms of my policy. I understand and agree to pay any unpaid balance not covered by my insurance company. In the event my account is turned over to collection, I hereby agree to pay all collection cost and fees.
I understand that my insurance company may not cover all charges incurred at Partners in Physical Therapy and that insurance companies do not guarantee payment, therefore I will be responsible for these charges.
Patient/Guardian Signature ______Date: ______
Social Security Number of Patient ______Patient Date of Birth ______
Lymphedema Evaluation
Name:______Date:______
1. How long have you had swelling?______
2. Have you ever had any infection?______
3. Do you ever leak fluid?______
4. Do you take antibiotics to prevent infection?______
5. Do you take diuretics for swelling?______
6. Do you take benzopyrones for swelling?______Don’t know______
7. Do you take any other drugs for swelling?______
8. Does anyone in your family have swelling?______
9. Which extremity has swelling? (check all that apply)
Left Arm______Right Arm______
Left Leg______Right Leg______
10. Have you had prior treatment for swelling? (check all that apply)
Surgery______Compression sleeve______
Antibiotics______Pump______
Manual Lymphatic Drainage______Physical Therapy______
Other______
11. Do you have bronchial asthma?______
12. Do you have hypertension?______
13. Do you have diabetes?______
14. Do you have allergies?______
15. Do you have any heart problems?______
16. Do you have any circulatory problems?______
17. What medications are you currently taking?______
______
______
18. Have you ever had a stroke?______
19. Have you ever had a DVT (blood clot)?______
20. Do you have Diverticulitis, Chron’s Disease, or Ulcerative Colitis?______
21. Do you have pain?______
22. Have you had cancer?______
23. Do you currently have an active cancer?______
24. Are you currently receiving treatment for cancer?______
25. Have you ever had radiation?______
26. Have you ever received chemotherapy?______
27. What operations have you had?______
______
28. If you are treated at this office, you will be then asked to follow a maintenance program at home.
This consists of:
a. Elastic sleeve or stocking worn during the day.
b. Bandaging of the limb overnight.
c. Meticulous skin care to avoid infection.
d. Remedial exercises to accelerate lymph flow.
Are you prepared to follow such a program?______
Please Be Advised:
It is office policy that the patient is responsible for any supplies that may be needed throughout the course of treatment. Partners in Physical Therapy will collect the balance at the time the supply is provided. Should you wish to file a claim on your behalf our office will provide you with the necessary documentation to do so. Thank you for your consideration regarding this matter.
Patient Signature: ______
Date: ______
Examples of supplies include: (Based on Necessity)
1. Electrodes $7.50
2. Theraband $1.00 per foot
3. Bracing and Orthotic Supplies
4. Kineso Tape $2.00 per foot
5. Dry Needling Needles $0.25 per needle
6. Lymphedema Garment and Supplies
7. Wound care Supplies