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: _____________________________________________________________________________________
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_____________________________________________________________________________________ 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) ___________________________________________
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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____
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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):
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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:
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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
________
________
________
________
________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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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
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_______________________________________________
_______________________________________________
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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:
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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.
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Beneficiary Signature
Date