Forms - Nelson Wellness Center
New Patient Consent to the Use and Disclosure of Health Information For Treatment, Payment, or Healthcare Operations I, ____________________________, understand that as part of my health care, NELSON WELLNESS CENTER originates and maintains paper and/or electronic 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 contributes to my care, • A source of information for applying my diagnosis and surgical information to my bill, • A means by which a third-‐party payer can verify that services billed were actually provided, and • A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals. I understand that I have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: • The right to review the notice prior to signing the consent, • The right to object to the use of my health information for directory purposes, and • The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations. I understand that NELSON WELLNESS CENTER is not required to agree to the restrictions 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. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations. I further understand that NELSON WELLNESS CENTER reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should NELSON WELLNESS CENTER change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or, if I agree, email). I wish to have the following restrictions to the use or disclosure of my health information: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ I understand that as part of this organizations treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax. I fully understand and accept/decline the terms of this consent. ____________________________________________ Patients Signature ____________________________________________ Date For Office Use Only [ ] Consent received by ______________________________ on __________________________. [ ] Consent refused by patient, and treatment refused as permitted [ ] Consent added to the patient’s medical record on ___________________________________. NELSON WELLNESS CENTER INTAKE FORM Date pt first contacted(NPT staff)_______________ Initial evaluation scheduled for ________________________ Patient Full Name _______________________________________________________________________ Street Address___________________________________________________________________________ City___________________________ State____________________ Zip Code________________________ Phone_________________________EmergencyPhone_______________________Cell ________________ Date of Birth___________________ Age__________ Social Security #______________________________ Email Address_______________________________________________(If you wish to receive our newsletter) Name of Primary Insurance________________________ Insurance ID#__________________________ Name of Secondary Insurance________________________ Insurance ID#_________________________ Name/DOB Primary policy holder (if other then self) ___________________________________________ • • • What is the date of your PT referral_________________________ If BCBS Health Keepers/MAMSI/Humana/Tricare-Prime Have you been pre-certified by your PCP for the first PT visit? Is your injury due to a motor vehicle accident? __________ ARE YOU CURRENTLY RECEIVING THERAPY OR NURSING SERVICES IN YOUR HOME OR AT A HOME HEALTHCARE CENTER AT THIS TIME? YES _____ NO_____ IF NO, WERE YOU FORMERLY DISCHARGED FROM YOUR HOME NURSE/IN HOME THERAPY OR HOME HEALTHCARE CENTER THERAPY? YES____ DATE OF DISCHARGE____________ NO____ _____________________________________________________________________________________________________ Employment status: (check one) _____ Employed ______ Full/part time student ______ Retired Employer/School______________________ Employee Phone Number_____________________________ Address_______________________________________________________________________________ City _______________________________ State_______________ Zip Code__________________ Occupation_____________________________ Supervisor’s name ________________________________ Is your injury: (check one) ______ Work Related _____ Auto Accident _____ Neither _______ School related If so, write the carrier: _____________________________________ Date of injury ___________________ Claim/referral no.___________________ Contact person _______________________________________ Phone number of contact person ______________________________________ Carrier address: Referring Doctor’s name: _________________________ Phone Number: ___________________________ Specialty:_______________________ Primary Care Physician________________________________ How did you hear about Nelson Physical Therapy? ____I was a previous patient ___Website _____Employer _____Friend (friend’s name:__________________) ____physician referral ____Yellow Pages ____Other PATIENT HISTORY Name______________________________________ Date________________________ 1. Where are your symptoms located? (Darken areas on body diagrams above.) 2. When did your symptoms begin? ___________________________________ 3. Are your symptoms related to: q Accident q Trauma q Gradual Onset q Work Related Injury Describe: _______________________________________________________________ 4. What makes you feel better? _______________________________________ 5. What makes you feel worse? _______________________________________ 6. Circle the words that best describe your symptoms: SHARP ACHE BURNING TINGLING STABBING THROBBING 7. What is your PAIN on a scale of 0 to 10, with 0 being NONE, and 10 the worst pain imaginable? ______________ 8. Even if unrelated to the current ailment, have you (Check the one that best applies) q I have had 0 falls in the past 1 year q I have had 1 fall in the past 1 year, without injury q I have had 1 fall in the past 1 year, with injury q I have had 2 or more falls in the past 1 year 9. Have you been seen for this ailment by another healthcare practitioner within the past 4 months? q No q Yes Who? ________________ Treatment: _____________________ 10. Please list any relevant diagnostic tests: _________________________________________ 11. Employment Status: q Full Time q Part Time q Out of Work q Light Duty q Retired Medical History Questionnaire To ensure you receive a complete and thorough evaluation, please provide us with the important background information below. If you do not understand a question, leave it blank and your physical therapist will assist you. Thank you! NAME: ____________________________________ Today’s Date: ___________________________ Allergies: List any medication(s) you are allergic to: ________________________________________ Are you latex sensitive? _____Yes _____No List any allergies we should know about: _______________________________________________ Please check any of the following whose care you are under currently: ____ Medical Doctor ____Psychologist/Psychiatrist ____Osteopath ____Physical Therapist ____Dentist ____Chiropractor ____Other:________________________________ If you have seen any of the above in the last 4 months, please describe for what reason(s): ___________________________________________________________________________________ PAST MEDICAL HISTORY Have you ever been diagnosed as having any of the following conditions? __Yes __No Cancer (If yes, please describe: ___________________________________) __Yes __No Heart Problems/ Heart Attack __Yes __No Circulation Problems __Yes __No Infection (staph, strep, C-diff, etc.) __Yes __No High Blood Pressure __Yes __No High Cholesterol __Yes __No Angina or chest pain __Yes __No Asthma __Yes __No Emphysema/Bronchitis __Yes __No Tuberculosis/Other Lung Disease __Yes __No Kidney Disease __Yes __No Thyroid Problems __Yes __No Diabetes __Yes __No Arthritis (Rheumatoid, Osteo or other arthritic conditions) __Yes __No Chemical Dependency/Addiction (i.e. alcoholism) __Yes __No Multiple Sclerosis __Yes __No Epilepsy/Seizures __Yes __No Depression __Yes __No Hepatitis __Yes __No Stroke __Yes __No Anemia __Yes __No Osteoporosis/Osteopenia __Yes __No HIV/AIDS __Yes __No smoke cigarettes/cigar/chew tobacco (_____# per day) __Yes __No Peripheral Neuropathy __Yes __No Lyphadema __Yes __No Parkinson’s Disease __Yes __No Other: _____________________________________________ If you checked “Yes” for any of the above, please explain: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Please list any surgeries or other conditions for which you have been hospitalized, including the approximate date and reason for the surgery or hospitalization (that you have not listed already): 1. 2. 3. 4. 5. DATE REASON FOR SURGERY/HOSPITALIZATION ________ ________ ________ ________ ________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Please describe any significant injuries for which you have been treated (including fractures, dislocations, sprains) and the approximate date of injury: 1. 2. 3. DATE INJURY ________ ________ ________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 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 FOR WOMEN: Are you currently pregnant or think you might be pregnant? __Yes __No Has anyone in your immediate family (parents, brothers, sisters) ever been treated for any of the following? (circle those that apply) Diabetes Cancer Kidney Disease Stroke Arthritis Heart Disease Tuberculosis Mental Illness High Blood Pressure Headaches Anemia Alcoholism/Chemical Dependency Epilepsy Which of the following OVER-THE-COUNTER medications have you taken in the last week? __Yes __No Aspirin __Yes __No Antihistamines __Yes __No Tylenol __Yes __No Antacid __Yes __No Advil/Motrin/Ibuprofen __Yes __No Vitamins/Mineral Supplements __Yes __No Laxatives __Yes __No Other: ______________________________ __ Yes __ No Decongestants Please list any PRESCRIPTION medication, with dosages, you are currently taking, (INCLUDING pills, injections, and/or skin patches): you may attach a separate list. 1. 2. 3. 4. 5. 6. MEDICATION DOSAGE _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ How many caffeinated beverages (coffee or other beverages) do you drink per day? _______________________ How many days per week do you drink alcohol? ______________ If one drink=one beer or glass of wine, how many do you drink in an average sitting? ______________________ Have you recently noted the following? __Yes __No Weight Loss or Gain __Yes __No Nausea/Vomiting __Yes __No Dizziness/ Light Headedness __Yes __No Fatigue __Yes __No Weakness __Yes __No Fever/Chills/ Sweats __Yes __No Numbness or Tingling Do you exercise regularly (2-3x/wk)? __Yes __No Do you have any medical problems that would limit your ability to exercise? __Yes __No If yes please explain: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ______________________________________ __________________________________________ Patient’s Signature Physical Therapist’s Signature Date Date NELSON WELLNESS CENTER INFORMED CONSENT I consent to receive physical therapy services that are deemed medically necessary by my referring and/or primary care physician. I authorize the release of medical information to my referring physician and insurance company. I hereby assign all benefits to be paid to Senior Journeys, LLC D/B/A NELSON WELLNESS CENTER. I understand that it is my responsibility to obtain pre-authorization of physical therapy if required by my insurance company. I understand that NELSON WELLNESS CENTER requires payment at the time of service for all co-pays and deposits for office visits. I am aware that NELSON WELLNESS CENTER will submit charges for services to my insurance company unless I make other arrangements. In consideration for this service, I understand that NELSON WELLNESS CENTER expects payment of the remaining balance within 7-10 days after receiving a statement. I realize that I am responsible for all charges incurred, regardless of payment by my insurance company. Any charges not paid by my insurance company will become my responsibility within 30 days. If your care is under litigation, I assign any proceeds due from physical therapy treatment from any cause of action, whether from a court award or settlement, in the hand of my attorney, the responsible party, or the insurance carrier for the responsible party to NELSON WELLNESS CENTER. I authorize and direct my attorney to pay all outstanding bills to NELSON WELLNESS CENTER from the proceeds of any settlement. A monthly finance charge of 1.5% of the outstanding balance, with a minimum of fifty cents will be applied to my balance after thirty (30) days. If it becomes necessary for my account to be assigned to a collection attorney, I agree to pay all collection cost and attorney fees. This includes legal fees at the rate of 25% of the outstanding balance. I understand there is a forty five dollar ($45) fee for cancellations of appointments or “no shows” without providing 24 hour notice. ___________________________________ Patient Signature _____________________ Date ___________________________________ Parent or legal guardian if under age 18 ______________________ Social Security Number Nelson Physical Therapy MEDICARE ADVANCE NOTICE TO BENEFICIARY Medicare requires that every Medicare patient read and sign this form to comply with Sections 1842(1) and 1879, Advance Notice Requirement, which affect both assigned and non-assigned claims. Medicare will only pay for services that it deems to be “reasonable and necessary” under Section 1862(a)(1) of the Medicare law. If Medicare determines that a particular service, although it would be otherwise covered, is not “reasonable and necessary” under Medicare program standards, Medicare will deny payment for that service. We believe that, in your case, Medicare is likely to deny payment for the following reason(s): ___ Medicare does not usually pay for this many visits or treatments X Medicare does not pay for this service (Supplies and Maintenance therapy) ___ Medicare does not pay for this service for your diagnosis ___ Medicare does not pay for this because it is a treatment that has yet to be proven effective (experimental) *Starting January 1, 2015, Medicare has imposed $1940 cap per year on outpatient physical Therapy and Speech services. You will be responsible for the amount that is not covered. I have been notified by my physical therapist that he or she believes that, in my case, Medicare is likely to deny payment for the services identified above, for the reason(s) stated. If Medicare denies payment, I agree to be personally and fully responsible for payment. ________________________________ ___________________________ Beneficiary Signature Date
© Copyright 2024