Moscow Mountain Sport & Physical Therapy
Consent for treatment, HIPPA and billing agreement
Information for patients without insurance:
If you do not have insurance coverage, you will be expected to pay for your bill, in full (we give a 25% cash discount), at the time of service, or make appropriate payment arrangements with one of our administrative staff members. For your convenience we accept cash, checks, Care Credit, major credit cards and debit cards that carry the Visa or MasterCard logo.
Information for patients with insurance:
Insurance coverage is a contract between you, your insurance company, and in many instances your employer. As a courtesy to you, we will file your medical claim with your insurance company in a timely manner. In most instances, we will accept payment directly from your insurance company in accordance with your policy’s terms and apply the payment to your account. Contractual discounts will be applied at that time.
You are responsible for any co-payment, co-insurance, or deductible. Co-pays are expected at the time of service. Patient bills are sent out on the 1st of each month and are to be paid in full by the 15th of that month. You are expected to know your co-pay and deductible amounts. We accept payment plans only through Care Credit. Please ask the office staff for an application or visit www.carecredit.com.
You will receive periodic statements indicating that we have billed your insurance company on your behalf. However, you are ultimately responsible for payment of your physical therapy services.
If your insurance company fails to pay your claim in a timely manner, or rejects your claim in part or in full, you are personally responsible for, and will be billed directly for the services you received. If that happens you may want to contact your insurance company directly or your insurance plan administrator at your place of employment to discuss the reason for the denial of benefits.
Accounts over 60 days past due will accrue interest at the rate of 1.5 percent (%) per month. We will charge you $30.00 for each returned check. You are responsible for the reasonable costs of collection on your account, including the reasonable attorney fees and costs we incur.
· I have read and agree to the terms of this statement.
· I have been provided and understand the MMSPT privacy / HIPPA policy which outlines the protection, disclosure and use of protected health information.
· I consent to receive Physical Therapy care at Moscow Mountain Sport & PT
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Signature of Patient Date Printed Name of Patient Date
***I have read and agree to the terms of this statement, and further agree to be jointly
liable for services rendered to the above-named patient***
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Signature of parent/guardian Date Printed name of parent/guardian Date
Or Responsible Party
Moscow Mountain Sport & Physical Therapy
PATIENT INFORMATION:
Name ______Date of Birth ______Age ______
Last First MI
Sex: Male Female Marital Status: Single Married/Partner Email: ______
Mailing Address ______City______State______Zip______
Permanent Address (if different from current address) ______
Home Phone ______Work Phone ______Cell Phone ______
Employer ______Occupation______Student Retired
Preferred method for appointment reminders: Text Email Phone Call
How did you hear about MMSPT? Physician Phone Book Internet Friend Other
Responsible Party (if different from patient):
Name: ______(Parent Name)
Address: ______Phone #: ______
PHYSICIAN INFORMATION:
Referring Physician ______Primary Physician ______
ACCIDENT INFORMATION: Type: Work Auto Sport Other
Date of Injury: ______Claim #______Place of Injury:______
Brief Description of Injury:______
______
INSURANCE INFORMATION: (If you have your insurance card we can copy and you do not need to fill this part out).
Primary Ins. ______Subscriber Name______
Date of Birth ______Policy # ______Group # ______
Secondary Ins. ______Subscriber Name ______
Date of Birth ______Policy # ______Group # ______
***No Insurance: Pay at time of service unless prior arrangements made.
Name______ Age ______Date ______
What are your main complaints or concerns (what brought you to therapy)? ______
How has this problem affected your ability to do the things you need or like to do? ______
What is your main goal or objective in coming to therapy? ______
______
If any, what other treatment has been tried for this problem (medications, chiropractic, ice…)? ______
MEDICARE PATIENTS: Have you fallen within the last year? Yes No
If yes, how many times? _____ Were you injured in the fall(s)? ______
When did your symptoms begin? (as close to the actual date as possible)______.
Pain Scale (circle the one which most reflects your pain today):
0------1------2------3------4------5------6------7------8------9------10
No pain Severe pain
How would you rate your overall health (circle one): Excellent Good Fair Poor Very Poor
Past Medical History: Please mark any you have or have had
Cancer: please list / DiabetesSurgeries: please list / Head Injury
Heart problems: / Seizures
Do you have a pacemaker? Yes No / Stroke
Arthritis: / Lung problems
Tape or latex allergies Yes No Any other allergies? / High blood pressure
Vascular problems: / Depression
Hospitalizations: please list / Thyroid problems
Other: / Kidney problems
Medications (Prescription and Over the Counter) or supplements you are currently taking:
Name / Dosage / Frequency (circle one): / Form (circle one):_____ times a day / week / Oral Injection Other:
_____ times a day / week / Oral Injection Other:
_____ times a day / week / Oral Injection Other:
_____ times a day / week / Oral Injection Other:
*If medication outnumbers four, please attach a separate list or use the back of this page.
Other information you think would be helpful for us to know ______