Sports Injuries in Henry County, GA | Physical Therapy in Motion Inc.

Date *

Name *

First

Last

Gender *

Male
Female

Date of Birth *

Age *

SSN *

Phone Number *

Work Number *

Home Address *

Occupation *

Work Address *

Emergency Contact Name *

Emergency Contact Phone Number *

Policy Holder Information

Relationship to Patient *

Self
Spouse
Parent
Other

Policy Holder Name *

First

Last

Gender *

Male
Female

Date of Birth *

Age *

SSN *

Work Number *

Occupation = *

Employer *

Work Address *

Primary Insurance *

Policy Number *

Group Number *

Past Medical History

Do you have now or ever had, any of the following?

High Blood Pressure
Osteoporosis
Seizures

If YES to any of the above, please explain and give appropriate details:

Are you Presently taking any medications? If YES, please list your medications and what condition:

Have you had any X-rays, CAT scans, MRI's, or other diagnostic tests done on you lately? If YES, please explain the findings as you understand them:

Is there anything else you think I should know about your general health, or current condition? Please explain and, if necessary, we can talk about it:

Primary Physician

REFERRING INFORMATION: Primary Physician

Address: (Street, City, State, Zip)

Phone Number

Fax Number

Specialist

Specialist Name

Address: (Street, City, State, Zip)

Phone Number

Fax Number

Injury Information

Date of Injury

Area(s) of the Body Injured

This Injury Was Due to:

Auto Accident
Work-Related Accident
Other

Please Explain:

Have you ever received physical therapy for this injury before:

IF THIS INJURY IS DUE TO AN AUTO ACCIDENT OR WORK, PLEASE GIVE THE FOLLOWING INFORMATION: Worker Compensation / PIP Carrier:

Address (Street, City, State, Zip)

Adjuster

Adjuster's Name

Phone Number

Your Claim #

Bill To

Attorney

Do You Have An Attorney?

Electrodes for Electrical Stimulation For hygienic purposes, it is recommended to purchase brand new electrodes for use during electrical stimulation treatment. There will be a one time, $10.00 fee collected at time of treatment for these electrodes. This fee cannot be billed to your insurance company. However, this is not mandatory. Patients will have the option to accept “used” electrodes at no additional cost.

Yes, please use brand new electrodes for electrical stimulation and I agree to a one time, $10.00 fee.
No, I agree to accept “used” electrodes for electrical stimulation at no additional cost.

I HEREBY AUTHORIZE THE PHYSICAL THERAPISTS AT PHYSICAL THERAPY IN MOTION INC. TO FURNISH THE AFOREMENTIONED MEDICAL REPORTS WHICH MAY BE REQUESTED IN REFERENCE TO MY TREATMENT. THE SAME MAY BE INCLUDED AS PART OF PROOF OF LOSS SUBMITTED BY MYSELF TO THE COMPANY.

Medical Facility:

I HEREBY DIRECT AND AUTHORIZE ___________________INSURANCE COMPANY TO PAY ANY AND ALL UNPAID BILLS IN MY CLAIM DIRECTLY TO PHYSICAL THERAPY IN MOTION INC. FOR PROFESSIONAL SERVICES RENDERED.

Insert insurance company*

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

I HEREBY AUTHORIZE THE PHYSICAL THERAPISTS AT PHYSICAL THERAPY IN MOTION INC. TO OBTAIN AND FURNISH ANY MEDICAL REPORTS, INCLUDING MEDICAL HISTORY, CONSULTATION, DIAGNOSTIC TESTS, AND PRESCRIPTIONS.

I HEREBY DIRECT AND AUTHORIZE SAID INSURANCE COMPANY TO PAY ANY AND ALL UNPAID BILLS IN MY CLAIM DIRECTLY TO PHYSICAL THERAPY IN MOTION INC. FOR PROFESSIONAL SERVICES RENDERED.

INSURANCE DISCLAIMER

I ACKNOWLEDGE AND AGREE THAT I AM INDIVIDUALLY RESPONSIBLE FOR ALL PAYMENTS OF MEDICAL SERVICES RENDERED BY PHYSICAL THERAPY IN MOTION INC., AND I HEREBY AGREE TO PAY ALL AMOUNTS DUE WITHIN 30 DAYS FROM THE BILLING DATE.

I REQUEST THAT PHYSICAL THERAPY IN MOTION INC. SUBMIT THEIR BILLINGS DIRECTLY TO MY INSURANCE COMPANY, AND I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO PHYSICAL THERAPY IN MOTION INC.

CANCELLATION POLICY

WE AT PT IN MOTION INC. WOULD LIKE TO THANK YOU FOR SELECTING OUR OFFICE TO MEET YOUR REHABILITATION NEEDS. WE MAKE EVERY EFFORT TO PROVIDE EXCELLENT SERVICE TO FACILITATE YOUR INDIVIDUAL HEALING PROCESS. HOWEVER, THIS REQUIRES A TWO-PART EFFORT, YOURS AND OURS!

PLEASE REVIEW THE FOLLOWING:

Together, your doctor and physical therapist have decided an appropriate treatment plan for you, including procedures and frequency of sessions. We reserve the time slot for land and aquatic therapy especially for you when appointments are scheduled.

It is greatly beneficial for you to keep your appointments in order to receive maximal benefit from our service.

If you are unable to keep your scheduled treatment time due to “unforeseen circumstance,” you must give us 24-hours notice.

If you fail to call or provide 24-hour notice of broken appointments, we reserve the right to charge a $75.00 fee.

If scheduled for aquatic therapy, please note a fee, of $15.00 will apply for switching to land therapy if a 24-hour notice is not given. This is necessary due to the limited slots available for aquatic therapy.

This fee can not be billed to your insurance company. You will be held personally responsible. If you fail to show for 3 consecutive appointments, we will discontinue physical therapy treatment and notify your doctor of poor compliance.

REMEMBER: We are a business that provides a health care service. When you fail to keep your scheduled appointments, this places a financial burden on our office.

Notice of Privacy Practice

Physical Therapy in Motion Inc.

Privacy Notice Required Under Federal Law

This Privacy Policy is provided to you as a requirement of the Federal Health Insurance Portability and Accountability Act (HIPAA), which protects how personal and medical information about you may be used and disclosed and your right to gain access to this information. Please review the information provided in this notice carefully and sign and return the attached certification of your receipt of this notice before you leave. Thanks you in advance for your attention and cooperation.

What is our Privacy Policy Notice?

It is our goal at Physical Therapy in Motion Inc. to keep your personal and medical information private, secure and confidential. We are providing our Privacy Policy Notice to you as required by the federal law and pledge to you that we will use and disclose your personal information consistent with that law. In the event that we change or modify our Privacy Policy those changes will apply to both information we already have about you and information we may gather in the future.

What kind of information is protected under the law?

In addition to the federal law, there are other laws that may have requirements for personal and medical information privacy. Under the law requiring this notice "health information" is information about your health care unique to you or individually identifiable information. "Personal information" includes both health information and personal information about you that facilitate our being able to provide service to you such as your social security number, home address, insurance coverage, and employment information, for example.

What types of information do we gather from you?

So that we can provide quality health care services to you as well as get paid for our services, we may ask you to fill out a medical background questionnaire detailing your personal data such as name, address, telephone number, date of birth, marital status, emergency contact, type of insurance, medical history, including present health conditions, allergies, symptoms, family history of illness and recent health care services or visits to providers.

How do we protect your confidential or personal data?

We only use and disclose your personal information within our organization in order to provide you with medical treatment or service. We disclose your information to those outside our organization from whom we receive a referral to provide you with services, providers to whom we may refer you to get health care service, and to those who process and/or pay for our services we provide you.

We may also disclose your personal information in the course of maintaining our health care operations such as certification for malpractice or other insurance or licensing requirements under state, local or federal law. For health care operations purposes, we only share your personal information with those entities who agree to use the information only for the specific purpose for which we disclosed your information to them, and not to use your information for any other purpose or reason, unless permitted or required by law.

Even when we disclose your personal information we limit our disclosure to only the information necessary to secure treatment, payment and/or health care operations. Our personal, staff and any contractors we control or supervise receive training and education regarding our privacy and security policies to protect your personal information.

How do we use your information and to whom might we disclose your personal information?

The law that requires us to provide you with our Privacy Policy Notice authorizes us to use and disclose your personal information in order to treat your condition, get paid for our services and maintain our health care operations. The following are some, but not all, instances allowed by law for using and disclosing your personal information:

Treatment. We may use and disclose your information for treating you and providing direct or indirect medical services prescriptions or pharmacy benefits.

Payment. We may use and disclose your information to submit claims to third-party billers, insurers, and any other payment sources you provide to us including family or benefactors. In some instances, your insurance company may request documentation from your medical record to support eligibility and coverage for the services we provided. to you and are now seeking payment to coordinate payment if you have more than one insurance or payment source, or for medical necessity review. If you are covered by a government funded health program like Medicare, Medicaid, TRICARE or Railroad Retirement Medicare, we may have to provide your personal information as requested by those programs or their contractors who administer those programs.

Health Care Organizations. This may include but is not limited to certifications or licensing authorities, administrative operations, fraud and abuse enforcement activities, requests or inquiries, business transactions like the sale of all or part of our practice or financial funding for operations (sale, of accounts receivables for example).

Disclosures to You About You or Your Minor Children or Legal Dependents. We may notify you of your upcoming physical exams, visits or appointments scheduled, or related preventive medicine notices. If you have legal custody or power of attorney over children or infirm adults, respectively, we disclose personal information about them to you. If you become the charge power of attorney we may disclose personal information about you to the person or entity you given your power of attorney over your health care and /or personal affairs, whichever applies.

Legal Proceedings or Legally-Mandated Disclosures. Where compelled or required to by law, we will disclose your personal information pursuant to a court order or other mandatory legal request but will attempt to gain your authorization beforehand or at least notify you that the compulsory request had been made for your personal information. Again, we will limit any disclosure to the specific request made. Additionally, we will disclose your personal information in response to a public safety or overriding public interest purpose (overriding in that the public (usually law enforcement) right to have your information is superior to our right to keep such information confidential). These include but are not limited to:

1. Disclosure required to protect victims of abuse or neglect;

2. Disclosure required to prevent an impending health or safety threat;

3. Disclosure required to document disease, epidemics or other public alerts;

4. Disclosure required for tracking medical devices

5. Disclosure required by the military, for national security, worker's compensation or disability, state or local coroners and other as required by law.

What uses or disclosures that we may make must have your prior authorization?

These include: allowed marketing activities; disclosures to business associates (a lawyer representing you or a related party in a personal injury/malpractice claim or litigation); or disclosures to providers for care authorized by you but not directly related to the plan of care or treatment for which you came to us (for example, you have come to us for physical therapy or a physical exam but you might request a referral for a nutritionist, dentist, or psychiatrist). We will also seek your written authorization for uses and disclosures of your personal information not provided in this notice.

When we do seek your prior authorization, you can withdraw or rescind your authorization for disclosure at any time in writing and the withdrawal will apply only to future disclosures not to those made in the past. We keep medical records for patients for at least five years (and longer if required by law); if the pursuit of payment for services continues after we end our treatment of you, we may continue to make uses and disclosures of your information in order to get paid. Likewise, our duty under the law is to protect your personal information and not to make illegal uses and/or disclosures of that information after we cease treating you.

What right do you have to gain access to your personal information and/or how we may have used or disclosed your protected information?

Upon written notice under federal law, we will allow you to inspect and copy health information we maintain about you, free of charge or for a reasonable fee if the health information you request is more that a few pages or we may charge a reasonable fee if you make more than one request in a year.The exceptions to your right are psychotherapy notes, information gathered for a legal (criminal or civic) or administrative proceeding. With cause and in limited situations, we can withhold your inspection or copying of your health records.

You may also request that your health records be amended if you feel that your information is incorrect or incomplete. Any denial for amendment must be provided to you in writing.

You may also request that we restrict or limit our use or disclosure of your personal information and if reasonable, we may agree. That includes disclosure to confidential communication of your personal information to you while you are at work, at home or some other location you designate.

Finally, you may request a list of some disclosures we make of your personal information including in response to court orders, government licensing agencies, and similar organizations. Authorized uses and disclosures allowed under the Privacy Law would not be a part of the accounting provided to you. All accounting of disclosure requests must be for dates after April 14, 2003 and will be provided to you for free of charge or for a nominal fee to cover our costs in processing your request.

If you lose your copy of this notice simply let us know and we will provide you with another copy.

Where to file a complaint if you believe your personal information has been used or disclosed without your prior authorization, as the law requires?

If you feel that we may have used or disclosed your personal information in manner not consistent with the law, you may file a complaint directly with us by writing or contacting our Privacy Officer, Mrs. Mecole Leverette, 770-288-2441, 106 Vinings Drive, McDonough, GA, 30253. We promise to investigate and resolve any complaint you make with us. Alternatively, you may file a complaint with the Secretary, U.S. Department of Health and Human Services, 200 Independence Avenue, S. W., Washington, D.C. 20201, Attn: Office of Civil Rights (telephone 877-696-6775).

Physical Therapy In Motion Inc.

Thank You

PHYSICAL THERAPY IN MOTION INC. PRIVACY POLICY NOTICE AS OF APRIL 14, 2003

PATIENT CERTIFICATION OF RECEIPT OF PRIVACY POLICY NOTICE

I acknowledge that I have received and reviewed a copy of the Physical Therapy in Motion Inc. Privacy Policy Notice on this day of. Note: This document shall be kept on file in the Medical Record and/or in the HIPAA Privacy Notice Patient Certification File maintained in the office.

Patient Signature *

Email Address *

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