Symmetry Physical Therapy

Symmetry Physical Therapy
Patient Information Questionnaire
CONFIDENTIAL INFORMATION
The information contained in this questionnaire will be used to help determine the most appropriate therapy I treatment required to help restore your
highest functional ability. All information is considered confidential and will be released only to your physician unless prior written authorization is given.
Patient Name:
Nombre del Paciente
Sex:
Sexo
Date:
Fecha
....:Age:
Edad
DOB:--:---:--:---:--:-Fecha de Nacimiento
Height
Altura
_
Weight
Peso
_
Referring Physician I Medico Remitente:
_
What problems brought you to therapy I Que problemas Ie trajo a la terapia?
Have you ever been treated for this condition before?
Alguna vez ha recibido tratamiento para esta condici6n antes?
YIN
If yes, please explain / En caso afirmativo explicar:
_
15 this injury or condition caused by I Es esta lesion of condicion causada por:
Accident
-----------~Auto
Accidente de Auto
________
,Falll Accident
Caida / Accidente
___________
_________
Other
Otro
Wo~i~u~
Accidente de trabajo
How and where I Como y donde?
_
Do you now have or had any of the following I Tiene actualmente
Diabetes I Diabetes
High Blood Pressure I Alta Presion
Heart Disease I Enfermedad del Corazon
Heart Attack I Ataque del Corazon
Pacemaker I Marcapasos
Arthritis
Chronic headaches I Dolores de cabeza
cronicos
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
0
ha tenido alguno de los siguientes:
Hernia
Previous Surgery I Cirugia previa
Are you Pregnant I Esta embarazada
Sensitive to Hot I Cold I Sensible al calor
Cancer
Nervous Disorder I Desorden nervioso
Allergies I Alergias
0
frio
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
If yes to the above, please explain:
En caso afirmativo, explicar
_
Are you currently taking any medications I Esta usted tomando algun medicamento?
I certify by my signature that the foregoing information is accurate and truthful to the best of my knowledge.
que /a informacion anterior es exacta y verdadera a mi conocimiento.
Patient Signature
Date,
YI N
Yo certifico con mi firma
_
Symmetry Physical Therapy
Patient Information
*** PLEASE USE BLACK INK ONLY ***
Patients
First and Last Name
DOB
Nombre y Apellido del paciente
.-:Age,
Fecha de Nacimiento
Patient's SSN
----------Drivers
Numero de Seguro del Paciente
Lic. #
Numero de Licencia de conducir
Street Address
Direccion Fisica -----------------Ciudad
Zip Code
Daytime
Codigo Postal
Telefono de dia
Sex
Sexo
City
Phone,
_
Edad
_
State
Estado
_
Cell Phone
_
Telefono Celular
Mailing Address,
_
Direccion Postal
Employer
Empleador------------------'Direccion
Occupation
Ocupacion
Emergency Contact'-Contacto de Emergencia
Address
_
--:Work telephone,--:Telefono del Trabajo
Relationship
Relacion
_
Phone
Telefono
_
1. CONSENT TO TREATMENT. The undersigned consents to any medical treatment rendered to the above named
patient that may be considered advisable and necessary in the judgment of the Physical Therapist
, CONSENTIMIENTO PARA EL TRATAMIENTO. EI abajo firmante consiente a los servicios medicos prestados a el
paciente antes mencionado que se puede considerar conveniente y necesario a juicio del Fisioterapeuta.
2. RELEASE OF INFORMATION. The undersigned agrees that Symmetry Physical Therapy may release medical records
and other information necessary to secure payment from employers, insurance companies, health care service plans or
Workers Compensation carries.
DIVULGACION DE INFORMACION. EI abajo firmante esta de acuerdo en que Symmetry Physical Therapy puede dar
a conocer 105 registros medicos y otra informacion necesaria para garantizar el pago de 105 empleadores, las empresas de
seguro, las empresas de planes de servicio de atencion medica 0 Compensacion a los trabejadores.
3_ PAYMENT TERMS AND ASSIGMENT OF BENEFITS_ The undersigned authorizes payment to the above provider of
benefits due me under any terms of any insurance policy or policies that may cover provider's professional services
rendered to the above named patient I understand that I am financially responsible to the provider for services not paid by
said insurance policies. This responsibility includes services rendered but not authorized by the patient's health insurance
plan or when the provider is not contracted provider with the health insurance.
CONDICIONES DE PAGO Y ASIGNACION DE LOS BENEFICIOS. EI abajo firmante autoriza el pago al proveedor por
encima de las prestaciones por mi bajo los terminos de cualquier poliza de segura 0 politicas, que pueden cubrir los
servicios profesionales del proveedor prestados a el paciente antes mencionado. Entiendo que soy financieramente
responsable ante el proveedor de servicios no pagados por dicha poliza de seguro. Esta responsabilidad incluye 105
servicios prestados pero no autorizados por el plan de segura del paciente 0 cuando el proveedor no tiene contrato
professional con el plan de seguro de salud.
Signature,
Firma
_
Date
Fech-a-------------
Symmetry Physical Therapy
Please Read and Sign the FoUowing Statements
I request that payment of authorized Medicare benefits be made either to me or on my behalf of Symmetry Physical
Therapy, Inc for any services furnished me by that supplier. I authorize any holder of medical information about me
to release to the Health Care Financing Administration and its agents any information needed. to determine these
benefits payable to related services.
I understand that my signature request that payments to be made and authorize release of medical information
necessary to pay the claim. If other health insurance is indicate in item 9 of the HCFA 1500 form or elsewhere on
the other approved claim forms or electronically submitted claims, my signature authorizes releasing of the
information to the insurer or agency shown.
In Medicare assigned cases, the supplier agrees to accept the charge determination of the Medicare carrier as the full
charge, and the patient is responsible / ily for the deductible, coinsurance and no covered services. Coinsurance and
the deductible are based upon the charge determination of the Medicare Carrier.
Signature:
Medicare #
_
Consent to Treatment
The undersigned consents to the treatment which may be performed on an outpatient basis, including but not limited
to the physical therapy procedures, modalities, and therapeutic exercise.
Signature
_
Dare
_
Insurance Authorization and Assignment (Please Read)
I hereby authorize Symmetry Physical Therapy, Inc. to furnish information to insurance carriers concerning my
illness and treatment and I authorize Symmetry Physical Therapy Inc. to use and disclose my Protected Health
Information (PHI) for the purposes of treatment, payment and health care operations and I hereby assign to the
Physical Therapist and Symmetry Physical Therapy, Inc. all payments for medical services rendered to myself or my
dependents. I have received and reviewed Symmetry Physical Therapy's Notice of Privacy Practices and understand
it provides more detailed information about how Symmetry Physical Therapy may use and disclose my Privacy of
Practices.
I understand I am responsible for any amount not covered by the insurance. When a payment is made to Symmetry
Physical Therapy, I understand Symmetry Physical Therapy had the right to apply the payment to any outstanding
balances I may have with Symmetry Physical Therapy, I understand and agree that any credit granted to me shall by
paid promptly in accordance with terms and agreements, that Symmetry Physical Therapy may add one and half
percent (1-112%) per month to any balance owed, and in event of default I agree to pay reasonable collection of
charges and/or attorney fees.
Signature
Date,
_
_
SYMMETRY PHYSICAL THERAPY
12384 Palmdale Rd, Suite 202
Victorville, CA 92392
Phone (760) 955-8100 Fax (866) 526-5194
PATIENT RESPONSIBILITY/AUTHORIZATION
AGREEMENT
FINANCIAL RESPONSIBILITY:
Financial responsibility for services rendered rests with the patient and/or his/her family.
We are happy to bill your insurance as a courtesy but please understand that it is your
responsibility to make certain that the bill is paid in a reasonable amount of time. If for
any reason your insurance company does not pay any portion of your bill, you must
agree to make arrangements for prompt payment of the bill or contact your insurance
company.
Co-PaymentslDeductible:
You are responsible for your co-payment and deductible. If your deductible has been
satisfied, we will bill your health plan. If your deductible has not been satisfied, payment
is required at the time of service.
Collection Responsibility:
I understand that should Symmetry Physical Therapy send my account to a collection
agency in an attempt to collect a debt or recover any payments for services by
Symmetry Physical Therapy, I am responsible for any extra costs requested by
Symmetry Physical Therapy, or the COLLECTION AGENCY.
I,
above.
, Acknowledge and understand the
Patient Signature:
Date:
A copy of this can be considered an original document for Insurance purpose.
Symmetry Physical Therapy
NOTICE OF PRIVACY PRACTICES:
Acknowledgement of Receipt
By signing this form, you acknowledge receipt of the Notice of Privacy
Practices of Symmetry Physical Therapy. Our Notice of Privacy
Practices provides information about how we may use and disclose your
protected health information. We encourage you to read it in full.
Our Notice of Privacy Practices is subject to change. Ifwe change our
Notice, you may obtain a copy of the revised Notice by contacting our
facility.
I acknowledge receipt of the Notice of Privacy Practices of Symmetry
Physical Therapy, Inc.
Signature:
Print Name:
_
----------------------
Date: --------
P~~T~~
SfJ~fJ
12384 Palmdale Rd #202
Victorville, CA 92392
Phone: (760) 955-8100 FAX 1866-526-5194
CANCELLATIONI
Date:
_
Patient
008
Missed Visits
_
Reason:
sick
sick
sick
sick
sick
Comments:
NO SHOW
work schedule
work schedule
work schedule
work schedule
work schedule
travel
travel
travel
travel
travel
personal
personal
personal
personal
personal