Forms to Complete and Return

We want to welcome you to The Orthopedic Group. This packet contains important information needed for your appointment. Please follow these instructions carefully as you complete each form.

Please arrive 15 minutes prior to your appointment time so that we can review your paperwork.

Forms to complete and return:

__No Show Policy and letter: signed and dated

__Patient Information and Benefits form (please complete all patient information and highlighted areas)

Special instructions:

Auto and Workers Compensation patients: please bring your personal insurance information; we will need to have this as a secondary on file.

We will verify benefits at the office (if there is an issue, we will contact you)

__Health History and Systems Review (please complete)

__Patient Authorization: initial by each then sign and date at the bottom of the page

__Workers Compensation: complete Work Related Injuries Form (2 pages)

__Medicare Primary Insurance: Medicare Therapy Questionnaire and Secondary Insurance Form

Papers for you to keep:

__Welcome and Instruction Letter

__Notice of Privacy Practices

To view go to:

Or request a hard copy at your appointment

Forms you will complete in the office:

__Pain Diagram

__Outcome Measurement Form (will be based on what body part we are treating)

__Pain description form

__Informed consent for treatment

Date of 1st visit ______Time______Therapist ______

Patient Reminders:

Patient financial responsibility – co-pays, co-ins, etc. 

Bring script from physician 

Bring Insurance Card and Photo ID 

Wear or bring appropriate clothing – shorts, sneakers etc.

All completed forms (signed and dated) 

If a minor, will need parent/guardian signatures and ID 

We thank you for choosing The Orthopedic Groupand are looking forward to working with you and helping you reach your goals.

The Staff at The Orthopedic Group, Physical Therapy

No Show and Cancelation Policy

We strive to provide our patients with excellent service and quality care. Our commitment to your well-being and health care is something that we at The Orthopedic Grouptake very seriously.

Your commitment to your physical therapy program is critical to your success. We will recommend treatment and set goals for you. In order to reach those goals you must do your part and your most important part is to make each and every appointment.

We will give you an appointment card to keep track for your appointments. If you should misplace this, please give us a call to review your appointment dates. We expect you to keep all your appointments; however should you need to cancel please note that we require a 24-hour notice.

If you need to cancel please call our office within 24-hours of your scheduled appointment to reschedule. Our phone number is ______.

If you do not show for your scheduled appointment and have not called to cancel, you may be charged $25 for the missed appointment.

If you miss 3 consecutive appointments we may need to discontinue your treatment.

We thank you for choosing The Orthopedic Groupand are looking forward to working with you and helping you reach your goals.

The Staff at The Orthopedic Group, Physical Therapy

I have read and understand this policy:

______

Patient/GuardianDate

THE ORTHOPEDIC GROUP

PATIENT REGISTRATION

PERSONAL INFORMATION PRIMARY HEALTH INSURANCE

FIRST NAME MI LAST NAME
ADDRESS
CITY
STATE ZIP CODE HOME PHONE NUMBER
( )
WORK PHONE NUMBER CELL PHONE NUMBER
( ) ( )
E-MAIL ADDRESS
DATE OF BIRTH AGE SEX – M or F
SOCIAL SECURITY NUMBER
MARITAL STATUS
 SINGLE  MARRIED  DIVORCED  WIDOWED
PATIENT’S EMPLOYER OCCUPATION
STATUS:
 FULL TIME  PART TIME
BEST TIME TO REACH YOU: MAY WE CONTACT YOU AT WORK:
STUDENT STATUS:
 FULL TIME  PART TIME
SCHOOL NAME
SPOUSE’S NAME
SPOUSE’S SOCIAL SECURITY NUMBER
SPOUSE’S EMPLOYER OCCUPATION PHONE NUMBER
( )
INSURED’S NAME (EXAMPLE: SELF, SPOUSE, OR PARENT’S NAME)
NAME OF INSURANCE COMPANY
INSURED’S EMPLOYER
ID NUMBER GROUP NUMBER
COPAY AMOUNT INSURED’S BIRTHDATE
RELATIONSHIP TO PATIENT:
 SELF  SPOUSE  PARENT  OTHER

SECONDARY HEALTH INSURANCE

Name of parent/guardian if patient is a minor______

INSURED’S NAME EMPLOYER
NAME OF INSURANCE COMPANY
ID NUMBER GROUP NUMBER
COPAY AMOUNT INSURED’S BIRTHDATE
RELATIONSHIP TO PATIENT:
 SELF  SPOUSE  PARENT  OTHER

PLEASE READ, SIGN, AND DATE:

YOU WERE REFERRED BY:
YOUR FAMILY DOCTORS’ NAME IS: PHONE NUMBER
( )

EMERGENCY CONTACT:

NAME RELATIONSHIP
HOME PHONE NUMBER WORK NUMBER
( ) ( )

HISTORY AND SYSTEMS REVIEW

Patient Name: ______Nickname/Name Preference: ______

(First) (Last)(MI)

Date of Birth: ______Age: _____Male or FemaleHeight: ____Weight: _____

Marital Status: __ Single__Married __Widowed __Other

Occupation: ______

Leisure Activities: ______

Describe the reason for your visit: ______

Date of Injury: ______

When was the onset of your problem ______

What is the length of time your symptoms have been present? ______

Onset:(Check One)Gradual ___ Sudden ___

How did the problem occur? ______Contact or Non-Contact

Did you hear any NOISE associated with the onset of the injury? ______

Where was the pain initially felt? ______Now, where is it? ______

Did you have SWELLING immediately? ______

Type of Pain (Circle)Dull Sore Constant Intermittent Sharp Throbbing Bruised Burning

Have you had any previous or similar problems? ______

Are you CURRENTLY seeing any of the following:

Reason (If seen in past 3 months- illness, medical condition, physical exam, etc):

Medical Doctor: Yes/No ______

Osteopath: Yes/No ______

Dentist: Yes/No ______

Psychiatrist/Psychologist: Yes/No ______

Physical Therapist: Yes/No ______

Chiropractor: Yes/No ______

Date of last complete physical exam: Month ______Year______Physician ______

Please list any surgeries or other conditions for which you have been hospitalized:

Approx. Date Surgery / Hospitalization / Reason

______

______

______

Please describe any injuries for which you have been treated:

Approx. Date Injury (fractures, dislocations, sprains, strains)

______

______

______

Which of the following OVER-THE-COUNTER medications have you taken in the last week: (Circle)

AspirinAntacids Tylenol

Vitamins/Mineral Supplements Antihistamines Advil/Motrin/Ibuprofen

Laxatives Decongestants Other ______

Please list any PRESCRIPTION medication that you are currently taking (including pills, injections, or skin patch)

______

(Continued on page 2)

HISTORY AND SYSTEMS REVIEW (page 2)

Please list any ALLERGIES you may have (if you have no allergies, list NONE)

______

______

Could you be or are you pregnant? ______

How much caffeinated coffee or other caffeine containing beverages do you drink per day? ______

How many packs of cigarettes do you smoke per day? ______

How many days per week do you drink alcohol? ______

During the past month have you often been bothered by feeling down, depressed, or hopeless? ______

Have you or any of your family EVER been diagnosed as having any of the following: (circle all that apply)

Cancer:Cancer (Type: ) / SELF / FAMILY MEMBER: / Heart Problems / SELF / FAMILY MEMBER:
Asthma / SELF / FAMILY MEMBER: / High Blood Pressure / SELF / FAMILY MEMBER:
Emphysema/COPD / SELF / FAMILY MEMBER: / Depression / SELF / FAMILY MEMBER:
Hepatitis / SELF / FAMILY MEMBER: / Stroke / SELF / FAMILY MEMBER:
Anemia / SELF / FAMILY MEMBER: / Multiple Sclerosis / SELF / FAMILY MEMBER:
Tuberculosis / SELF / FAMILY MEMBER: / Diabetes / SELF / FAMILY MEMBER:
Chemical Dependency / SELF / FAMILY MEMBER: / Kidney Disease / SELF / FAMILY MEMBER:
Osteoporosis / SELF / FAMILY MEMBER: / Thyroid Problems / SELF / FAMILY MEMBER:
Rheumatoid Arthritis / SELF / FAMILY MEMBER: / Epilepsy / SELF / FAMILY MEMBER:
Other Arthritic Conditions / SELF / FAMILY MEMBER: / SELF / FAMILY MEMBER:

Have You Had, Or Do You Experience:

Cardiovascular SystemYES NO GI System YES NO

Elevated cholesterol ______Difficulty swallowing ______

Sweating associated with pain______Heartburn ______

Palpitations______Jaundice (yellow appearance) ______

Swelling of extremities ______Specific food intolerance ______

History of smoking______Constipation ______

Orthopnea (difficulty breathing)______Diarrhea______

Rectal bleeding______

G.U. SystemYES NOGall bladder problems______

Dysuria (painful urination)______Liver problems______

Hematuria (blood in urine)______

Incontinence______Pulmonary SystemYES NO

Urinary urgency______Dyspnea (labored breathing)______

Painful Menstration ______Wheezing______

Frequency in urination______Prolonged cough______

Neurological SystemYES NO Endocrine System YES NO

Poor Muscular Coordination ______Excessive thirst______

Memory lapses ______Excessive hunger______

Confusion______Fatigue______

Head Trauma______Weakness______

Neurological Disorder______Thyroid problems______

Tremors______

Slurred speech patterns______Other SystemsYES NO

Hearing/Visual disturbances______ENT (ears, nose, throat)______

Lymphatic______

Psychiatric______

Musculoskeletal______

The information listed is correct to the best of my knowledge.

Patient/Guardian Signature:______Date: ______

Patient Authorization

Patient Name: ______Date of Birth: ______

Release of Information & Consent for Treatment

All information provided herein is true and correct.

I am aware of my diagnosis and wish to receive treatment atThe Orthopedic Group. I permit its employees and all other persons caring for me to treat me in ways they judge are beneficial to me.I consent to rehabilitation and related services at this Facility. I understand, acknowledge and affirm that such rehabilitationand related services may involve bodily contact, touching and/or direct contact of a sensitive nature. I understand thatthis care can include an evaluation, testing, and treatment. No guarantees have been made to me about the outcome ofthis care.

I give permission to The Orthopedic Group to release information, verbal andwritten, contained in my medical record, and other related information, to my insurance company, rehab nurse, casemanager, attorney, employer, school, related healthcare provider, assignees and/or beneficiaries and all other relatedpersons as it relates to my treatment and/or payment for services provided. I authorize The Orthopedic Group to obtain medical records and/or professionalinformation from my physician or other medical professional as it relates to my treatment.The signature below certifies that I have read and understand the above information.

Initial: ____

Assignment of Benefits

I authorize payment directly to The Orthopedic Group, its subsidiaries and/or affiliates for services and to bill and release payment directly to The Orthopedic Group, its subsidiaries and/or affiliates for any physical therapy, rehabilitation, orthotic or prosthetic services provided.This is a direct assignment of my rights and benefits under this policy. A photocopy of this assignment shall beconsidered as effective and valid as the original.

Initial: ____

Notice of Privacy Practices (HIPAA Acknowledgement/Consent)

I hereby acknowledge that I have received a copy of The Notice of Privacy Practices for The Orthopedic Group. In addition, I hereby consent to the use and disclosure of my personal health information for the purposes of treatment, payment, and health care operations.

Initial _____

Payment Guarantee

I agree to pay The Orthopedic Group, its subsidiaries and/or affiliates for the services provided to me or the party named above. If any law, such as workers’ compensation, or insurance contract prohibits payment for these services I will cooperate and assist in the provision of information, authorizations, releases, or any other type of information necessary to allow for speedy collection from my third-party payer. Where the law or an insurance contract does not prohibit payment by me, I acknowledge responsibility for any and all account balances.

The Intake & Verification of Benefits Form is only an explanation of coverage obtained from my insurance company and

it is not a guarantee of coverage. If the information provided by my insurance company is not accurate or the insurance

company changes its coverage, I will be responsible for payment for services. I understand that my good-faith payment may not be inclusive of all payments for which I am responsible and I may be billed for any remaining balance.

I further understand that this agreement is binding regardless of any legal transaction currently in progress or initiated

during or after the course of my treatments unless agreed to in writing by myself and a representative of The Orthopedic Group.

Initial ______

Patient Information & Data Sheet

I hereby acknowledge that the information I provided on the Intake Form and all Patient Information is correct.

Initial: ______

Patient or Guardian Signature: ______Date: ______

Witness Signature: ______Date: ______