Paulseth & Associates Physical Therapy, Inc

PAULSETH & ASSOCIATES PHYSICAL THERAPY, INC

1950 CENTURY PARK EAST, 2ND FLOOR, LOS ANGELES, CA 90067

DAVID BARTON GYM

PHONE: 310. 286.0447 FAX: 310.286.1224 www.paulsethpt.com

PATIENT REGISTRATION

Patient name: __________________________________________ Date of birth: ________________________

Address: _________________________________ Apt #: ____ City: ______________ State: ___ Zip: _______

Phone #: _______________________ Cell #: _______________________ S.S. #: _______________________

Referred By: ___________________________________ E-mail: ____________________________________

Employer: _________________________ Occupation: ______________________ Phone: ________________

Date of symptoms/injury: _________________________ Date of surgery: _____________________________

Spouse’s name: _________________________ Spouse’s employer: _______________ Phone: _____________

Person to contact in case of emergency: ___________________________________ Phone: ________________

Where did you hear about our clinic: ____________________________________________________________

INSURANCE INFORMATION

Primary insurance: ____________________________ Secondary Insurance: __________________________

Name of insured: ________________ DOB: _______ Name of insured: ________________ DOB: ________

Patient’s relationship to insured: _________________ Patient’s relationship to insured: _________________

ID #: _______________________________________ ID #: _______________________________________

Employer: ___________________________________ Employer: ___________________________________

Ins. Phone: ___________ Group/Policy #: __________ Ins. Phone: ___________ Group/Policy #:__________

Medicare patients: Have you received home health care in the past 60 days for physical therapy Y □ N □

PRIOR THERAPY TREATMENT THIS YEAR

Number of visits: Physical Therapy: ________ Speech: ________ Occupational: _______ Chiropractic: ______

Assignment of Benefits

I HEREBY INSTRUCT AND DIRECT ___________________________________ INSURANCE COMPANY TO PAY DIRECTLY TO PAULSETH AND ASSOCIATES PHYSICAL THERAPY FOR THE PROFESSIONAL OR MEDICAL BENEFITS ALLOWABLE, AND OTHERWISE PAYABLE TO ME UNDER MY CURRENT INSURANCE POLICY.

THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY.

A PHOTOCOPY OF THIS ASSIGNMENT SHALL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL.

I ALSO AUTHORIZE THE RELEASE OF ANY INFORMATION PERTINENT TO MY CASE TO ANY INSURANCE COMPANY, ADJUSTER, OR ATTORNEY INVOLVED IN THE CASE.

Date: ___________________ Signed: ______________________________________________________

Paulseth & Associates Physical Therapy, Inc.

Financial Policy

PRIVATE INSURANCE: Our staff is pleased to directly bill your insurance company after your insurance coverage has been verified. Co-payments and annual deductibles will be collected at the time of service unless you have made other arrangements with our office administrator. Each benefit package is unique and each patient is advised to review their benefit material for coverage details. It is the responsibility of the patient or the person responsible for payments to remit any amount not covered by insurance. Insurance companies require claims to be submitted within a limited time period. If you fail to provide us with the correct insurance information on a timely basis, you will be responsible for full payment of all charges. Your Insurance policy is a contract between you and your insurance company. We cannot guarantee payment of your claim.

MEDICARE: We are a Medicare-certified facility and will file claims to Medicare on your behalf for covered services. We will also bill your supplemental insurance company. If you do not have supplemental insurance or have an HMO or Medi-Cal as your supplemental insurance, you will be billed for your patient responsibility portion after Medicare has paid. Medicare regulations do not permit us to waive the 20 percent patient responsibility. There is a cap to physical therapy benefits. Please ask our office administrator about the physical therapy cap for the current year.

PRIVATE PAY: This is for our patients with no medical insurance coverage for physical therapy, for patients with a health plan that Paulseth & Associates, Inc. is not a member of (out of network), for patients who do not present a current insurance card at the time of service, or for those who elect not to use their medical insurance coverage for services. Full payment is expected for all charges on the day of service. We accept cash, checks, debit, Visa, and MasterCard. We will not bill any health or liability insurance for you. If you as a Private Patient elect to submit claims to your own insurance company, we will provide chart notes to you. We cannot guarantee payment of the claim you submit. We will complete any reports, letters, and paperwork for a $50 per hour administrative and/or $200 per hour professional fee, whichever is required.

CALIFORNIA DEPT OF HEALTH SERVICES (Medi-Cal): We are not a Medi-Cal certified facility and will not bill Medi-Cal for our services. You will be responsible and liable for payment of all charges for professional services. Full payment is expected when services are rendered.

HEALTH MAINTENANCE ORGANIZATIONS (HMOs): We are not a member of any

Health Maintenance Organizations and will not bill your HMO for our services. You will be responsible and liable for payment of all charges for professional services. Full payment is expected when services are rendered.

LATE-FEE: I understand that a 1% monthly, 12% annual late fee will be applied to all patient balances 90 days old or greater.

RETURNED CHECKS: I understand that a check returned by the bank for insufficient funds will incur a $35 service charge. I will be asked to bring cash, certified funds or a money order to cover the amount of the check plus the $35 service charge to pay the balance prior to receiving services from our staff.

AGREEMENT TO PAY: I understand the Financial Policy detailed above. I understand and agree that I am responsible and liable for payment of all charges assessed for professional services rendered. In the event that my insurance company forwards payment directly to me, I will deliver such payment to Paulseth & Associates Physical Therapy, Inc. I understand that I am responsible for meeting my insurance deductibles, co-payments, and coinsurance, and my non-covered services. Should my account become past due, the balance becomes my responsibility and is immediately due. Should any unpaid balance be referred to a collection agency, I understand I am responsible for all costs of collecting moneys owed including court costs, collection agency fees and attorney fees, in addition to my outstanding account balance. Paulseth & Associates Physical Therapy, Inc. strongly recommends that you verify outpatient benefits with your insurance company.

Patient/Guardian Signature: ____________________________ Date: ___________________

Paulseth & Associates Physical Therapy, Inc.

Acknowledgement and Authorization

Patient Name _________________________________________________________________

I have read and fully understand the Financial Policy. I authorize my insurance benefits to be paid directly to Paulseth & Associates Physical Therapy, Inc. I am financially responsible for any balance not covered by insurance. I authorize the release of any information needed in the processing of my claim.

Patient/Guardian Signature: ____________________________Date: _____________________

I have read and fully understand the Cancellation, No-Show, Short Notice and Illness Policy and understand that I will be responsible to pay a $50.00 fee for no-show or short notice change of scheduled appointments and that the fee will be due at the time of my next appointment.

Patient/Guardian Signature: ____________________________Date: _____________________

Consent to Receive Voice Message Appointment Reminders: I consent to receive automated voice messages from Paulseth & Associates Physical Therapy, Inc. on my phone and any number forwarded or transferred to that number. I understand that this request to receive voice messages will apply to all future appointment reminders unless I request a change in writing. The phone number that I authorize to receive messages for appointment reminders is _________________________. The practice does not charge for this service, but standard rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details).

Patient/Guardian Signature: Date:

I have read and fully understand the Paulseth & Associates Physical Therapy, Inc. Notice of Information Practices. I understand that Paulseth & Associates Physical Therapy, Inc. may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment. I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I hereby consent to the use and disclosure of my personal health information for purposes as noted in the Paulseth & Associates Physical Therapy, Inc. Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.

Patient/Guardian Signature: ____________________________Date: _____________________

I agree and give my consent for Paulseth & Associates Physical Therapy, Inc. to furnish care and treatment considered necessary and proper in treating my condition.

Patient/Guardian Signature: ____________________________Date:______________________

PAULSETH & ASSOCIATES PHYSICAL THERAPY, INC

DESIGNATED INDIVIDUALS AUTHORIZATION FORM

I hereby authorize one or all of the designated parties below to request and receive the release of any protected health information regarding my treatment, payment or administrative operations related to treatment and payment. I understand that the identity of designated parties must be verified before the release of any information.

Authorized Designees:

Name: ______________________________ Relationship: _____________________

____________________________________

Patient Name

____________________________________

Patient Signature

____________________________________

Date

PATIENT HISTORY

To ensure you receive a complete and thorough evaluation, please provide us with the important background information on the following form. If you do not understand a question, leave it blank and your therapist will assist you. Thank you!

NAME: ____________________________ DATE OF BIRTH: __________________ OCCUPATION: _______________________

USUAL ACTIVITY LEVEL: _____________________________________________________________________________________

Allergies: List any medication(s) you are allergic to: ___________________________________

Are you latex sensitive? YES NO List any other allergies we should know about: _________________________________

Please check (✓) any of the following whose care you are under:

______ Medical doctor (MD) ______ Psychiatrist/Psychologist Other ________________

______ Osteopath (DO) ______ Physical Therapist

______ Dentist ______ Chiropractor

Date of last physical examination: __________________________

If you have seen any of the above during the past three months, please describe for what reason (illness, medical condition, physical, etc.):_______________________________________________

Have you had an infection within the past 6 weeks? YES NO

Have you ever taken immunosuppressive drugs? YES NO

Have you EVER been diagnosed as having any of the following conditions?

YES NO Cancer If YES, what kind: _______________

YES NO Heart problems If YES, what kind: ______________

YES NO High blood pressure YES NO Depression

YES NO Circulation problems YES NO Hepatitis

YES NO Asthma YES NO Tuberculosis

YES NO Stomach ulcers YES NO Stroke

YES NO Chemical dependency (i.e., alcoholism) YES NO Kidney disease If YES, what kind: ____________

YES NO Thyroid problems YES NO Liver disease

YES NO Diabetes YES NO Blood clots

YES NO Multiple sclerosis YES NO Osteoporosis

YES NO Rheumatoid arthritis YES NO Sexually transmitted disease

YES NO Crohn’s disease YES NO Other ____________________

YES NO Incontinence YES NO Autoimmune disease If YES, what kind: ________

Has anyone in your immediate family (parents, brothers, sisters) ever been treated for any of the following?

YES NO Diabetes YES NO Cancer

YES NO Heart disease YES NO Alcoholism (chemical dependency)

YES NO High blood pressure YES NO Depression

YES NO Stroke YES NO Kidney disease

YES NO Inflammatory Arthritis (Rheumatoid, Ankylosing)

During the past month, have you been feeling down, depressed or hopeless? YES NO

During the past month, have you been bothered by having little interest or pleasure in doing things? YES NO

Do you ever feel unsafe at home or has anyone hit you or tried to injure you in any way? YES NO

Please list any medications, vitamins, and/or supplements you are currently taking (prescription and nonprescription) and include the dosage and frequency:

1. __________________________________________ 2. __________________________________________

3. __________________________________________ 4. __________________________________________

5. __________________________________________ 6. __________________________________________

7. __________________________________________ 8. __________________________________________

How many packs do you smoke per day? _______ for how many years_______If quit, when? ________

How many days per week do you drink alcohol? _______

If one drink equals one beer or glass of wine, how much do you drink at an average sitting? __________

Please list any surgeries or other conditions for which you have been hospitalized, including the approximate date and reason for the surgery or hospitalization:

DATE REASON DATE REASON

__________ _____________________________ __________ ______________________________

Please describe any significant injuries for which you have been treated (including fractures, dislocations, sprains) and the approximate date of injury:

DATE INJURY DATE INJURY

__________ _____________________________ __________ ______________________________

Have you had any of the following diagnostic tests recently?

YES NO MRI YES NO X-Ray

YES NO CT Scan YES NO EMG YES NO Other: _____________________

Please mark the area of your current injury in the diagram below.

Have you RECENTLY noted:

YES NO Weight loss/gain YES NO Unexplained joint/muscle swelling

YES NO Nausea/vomiting YES NO Easy bruising

YES NO Dizziness/lightheadedness YES NO Excessive bleeding

YES NO Fatigue YES NO Difficulty breathing

YES NO Sudden weakness YES NO Regular cough

YES NO Fever/chills/sweats YES NO Arm/leg swelling

YES NO Numbness/tingling YES NO Heart racing in your chest

YES NO Tremors YES NO Difficulty swallowing

YES NO Seizures YES NO Heartburn/indigestion

YES NO Double vision YES NO Constipation/diarrhea

YES NO Loss of vision YES NO Blood in stools

YES NO Eye redness YES NO Post menopause

YES NO Skin rash YES NO Problems urinating (difficulty starting, painful, etc.)

YES NO Problems sleeping YES NO Urinary incontinence

YES NO Sexual difficulties YES NO Blood in the urine

YES NO Night sweats YES NO Pregnant or think you might be pregnant

YES NO Hearing problems YES NO Unusual stress at home or work

YES NO Abdominal pain YES NO Fainting

YES NO Pulsating sensation in abdomen YES NO Falling/balance/coordination problems

YES NO Any unusual vaginal bleeding

__________________________________ _________ _________________________________ ________

Patient Date Therapist Date