Therapeutic Evolution General Patients Form

Patient Registration

Today's Date*

Date of 1st Visit

Diagnosis/Reason for Treatment

Returning Patient?*

Yes
No

Payment Type

Self Pay
Insurance
Auto
Workers Comp

Patient Name*

First Last

Date of Birth*

Address*

Street Address City State ZIP Code

Gender*

Male
Female

Marital Status*

Single
Married
Divorced

Home Phone*

Work Phone

Cell Phone

Email*

Best Way to Contact*

Cell Phone
Home Phone
Email

Emergency Contact Name

Emergency Contact Name*

First Last

Relation*

Home Phone

Work Phone

Cell Phone

Physician Information

Referring Physician*

Office Phone

Primary Care Physician*

Office Phone

Have you had physical therapy before?*

Yes
No

When/Where?

Insurance Information

Primary Insurance*

Member ID#*

Group #

Subscriber Name

First Last

Subscriber Date of Birth

Relationship to Patient

Subscriber Phone

Address

Street Address City State ZIP Code

If different from patient

Secondary Insurance

Member ID#

Group #

Subscribers Name

First Last

Subscribers Date of Birth

Relationship to Patient

Subscriber Phone

Other

How did you hear about us?

If you are a returning patient, what brought you back to us?

Consent to Treatment

I hereby authorize the professional staff at Therapeutic Evolution Physical Therapy to examine and treat me with physical therapy for the injury I have been referred here for or referred myself to.

Patient Signature*

Assignment of Benefits and Release of Medical Information Instruction for Direct Payment to Health Provider

Insurance Company/Companies Name(s)

I hereby instruct the above-named insurance company/companies to pay by check made out to and mailed directly to: Therapeutic Evolution Physical Therapy (Assignee) for professional or medical expenses allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above- mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional fees for non-covered services and/or fees, over and above the insurance payment or as required by my insurance policy.

I hereby release Assignee, its officers, agents, employees and any clinical staff associated with my case, from all liability that may arise as a result of disclosure of information to the above-named insurance company(s) or their designated representatives. By signing this Assignment of Benefits and Release of Medical Information I acknowledge the following: I am aware and understand that this authorization will not be used unless the above named insurance company(s) or their designated representatives request records of information for reimbursement purposes; or seek to take action reference payment for treatment services, I agree to participate and assist Assignee or its designated representatives with any appeal process necessary to collect payments for services rendered, I understand that this assignment and authorization is subject to revocation at any time except to the extent that action has been taken in reliance thereof, I understand Assignee is acting in filing for insurance benefits assigned to myself and it can assume no responsibility for guaranteeing payment of any charges from the insurance company(s), I understand a firm contracted by Assignee for billing and collection purposes may do billing, I understand that Assignee is appointed by me to act as my representative and on my behalf in any proceeding that may be necessary to seek payment from my insurance carrier which includes receiving a copy of my insurance plan’s documents, I agree that should an overpayment take place, a refund check will be mailed to the authorized party that is due the overpayment, I agree that Assignee shall be entitled to the full amount of its charges without offset.

HIPAA REGULATIONS

I understand that Therapeutic Evolution Physical Therapy complies with HIPAA and will protect my Protected Health Information (PHI) and will use it as allowable by law in the treatment, billing and collection pertaining to my care until my case is closed and full payment is received. I also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney for the purpose of securing payment under this policy of insurance or to any Medical Provider associated with my case to effectively treat me. The authorization is in effect until 90 days from the date the last bill is collected.

I have received a copy of the Notice of Information Practices.*

Please Initial

A photocopy of this Assignment shall be considered effective and valid as the original.*

Please Initial

Patient Intake Form

Please describe your current complaint

How long have you had this current complaint?

List your past surgeries, injuries, or major medical problems: (be as specific as possible)

Are you currently being seen for any other medical problems? If so please describe:

What have you tried to treat this problem before?

What do you do that increases your complaint?

What do you do that decreases your complaint?

Have you had any special tests? (MRI, CT scans etc.)

What are your goals for therapy?

Patient Signatures

Patient Signature

Date

Patient Printed Name

First Last

Parent or Guardian Signature (if under 18)

Parent or Guardian Printed Name

First Last

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.