Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Being the parent or legal guardian of _____________________________ (minors printed name), I__________________________(parent/guardians printed name) hereby authorize Excel Therapy, LLC consent for Physical Therapy evaluation and treatment effective now or in the future of my minor child, born__________. Further, as parent or legal guardian, I am responsible for the health care decisions of my minor child and agree that my insurance plan is the primary plan to pay for the dental, medical, or hospital care or treatment that is given to my child. _____________________________________________________________ Signature of Parent or Legal Guardian __________________________ Witness Signature _______________________________ Witness Name (please print)
This consent form should be taken with the child to the hospital or physician's office when the child is taken for treatment. This additional information will assist in treatment if it can be furnished with the consent but is not required. Family address _________________________________________________ Telephone: Father ______________ home ________________ work Mother _____________ home ________________ work Child's Birth date ________________ Last Tetanus ___________________ Allergies to drugs or foods _______________________________________ _____________________________________________________________ Special Medications, Blood Type or Pertinent Information _____________________________________________________________ _____________________________________________________________ Child's Physician __________________________ Phone _______________ Insurance ________________________________ Policy # _____________ Preferred Hospital ______________________________________________
Patient Name: _____________________DOB: _______ Date: ________________________________________ Referring Physician: ____________________________ Primary Care Physician: _________________________
Excellent Care. Exceptional Results.
Medical History
Accidents, injuries, or major illnesses including motor vehicle (include date): _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Surgeries (include date): ____________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Medications, vitamins: _____________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Are you pregnant? Yes No If so, how many months? ______________
High or low blood pressure Diabetes Cancer Hepatitis or jaundice Anemia Palpitations Blood disorders Lightheadedness Heart disease Chest pain / tightness Stroke Circulation / blood clots
Bronchitis Pneumonia Persistant cough Tuberculosis Gall bladder disease Asthma Shortness of breath Swollen ankles Gout Kidney disease Kidney stones Difficulty urinating Frequent urination
Abdominal pain Colitis Indigestion Nausea Vomiting Unexplained weight loss Change in bowel habits Constipation Diarrhea Blood in stools Hemorrhoids
Severe headaches Anxiety Depression Thyroid disease Low back problems Osteoarthritis Rheumatoid arthritis Skin diseases Ulcers Joint / tendon / muscle pain Joint replacement Poor balance / falls Other_____________
Provide details regarding conditions checked above: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _____________________________________________________________________ Have you recently noted:
Excellent
Good
Fair
Poor
What type of exercise? _____________________________________________________ Was the onset due to: Injury Motor vehicle accident Slow onset Chronic Work related
Diagnostic testing Performed: Nerve conduction velocity EMG Bone scan MRI
Cardiac stress test CT scan Blood test Urinalysis Doppler studies x-rays
Do you have: Pins and needles Numbness Tingling Loss of sensation Hypersensitivity
Signature:___________________________________________________ Date:______________
Patient Information
Acct #:____________ Appt Date:_____/_____/_____ Completed by:________________ Name: _____________________________________________________
Last Street First City MI
______
State
________
Zip
Is this residence a: House_______Apt._________Assisted Living_________Other_______________ Sex: M F SSN#______-____-_______ Date of Birth:____/____/____ Marital Status: M S D W U Home Phone#: (_______)_______-_________ Work Phone #: (_______)_______-_______Ext______ Student: Y N If yes: Full-time or Part-time Cell Phone #: (______)_______-_________ Employer Name:_________________________________
Responsible Party:________________________________________________________
Last First MI
Address:_________________________________________City:___________________State________ SSN #:________-________-_________ Sex: M F Date of Birth:________/________/_________ Home Phone#(____)_____-______ Work Phone #(____)_____-_____ Ext____ Employer___________ Relationship to Patient:_____Self______Spouse_____Parent_____Other_________________________
____________________________________________ _____/______/_______ _________________ Insurance Verified By:____________________ Date:____/____/____ Per:________________________ Insurance Phone #: (_______)_______-________Insurance Fax #: (_______)_________-____________ CoIns. %:_________ Copay Amt:_________ Deductible Amt:__________ Amt of Ded Met:_________ OOP Max:_________________ Amt of Ded Met:_________________Visit Limit:________yr / incident Referral or Pre Cert / Auth Needed: Y N Auth #:__________________________ # of visits_________ Referring Physician:_________________ Phone # (_____)______-_______Fax # (_____)_____-_____ Primary Physician:__________________ Phone# (____) ______-______ Fax # (_____) _____-_______ Script Date:______/______/______ Frequency: ________________times per week for _________weeks Emergency Contact Name: ___________________________Relation to Pt:_______________________ Phone #: (________)_______-___________ext ________Cell #: (________)_________-____________ Surgery Date:_____/_____/_____ Accident Date:_____/_____/_____ Next Dr. Visit: _____/____/_____ Accident Type: None W/C Auto Athlete Other_______ Diagnosis_________________________
C. Protected Health Information(PHI) Any individually identifiable health or financial information, whether verbal, written, electronic, or otherwise recorded in any form or medium that: 1. Is created or received by Excel Therapy, LLC or one of their employees, agents, or assigns, and 2. Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual. Requirements 1. Excel Therapy, LLC, and their management, employees, and agents are expected to treat all PHI in any form (paper, electronic, verbal, etc.) as confidential in accordance with government regulations, professional ethics, legal requirements, and accreditation standards, and they: a. Will not divulge PHI unless the patient, parent or legally authorized representative has properly authorized the release or the release is otherwise required or permitted by law and in accordance with our policies. b. Will release only the reasonable minimum amount of information required by the requestor when a release is appropriately authorized. c. Will take appropriate steps to prevent unauthorized re-disclosures of PHI received from sources other than records. 2. Confidentiality Statement: All employees are required to sign a confidentiality statement before they are granted access to PHI. 3. Training: All employees are required to be trained on policies and procedures regarding confidentiality and PHI to the extent necessary for each individual member to carry out their assigned functions within. This training must be documented and retained with the employees personnel file. At a minimum training will occur: a. Upon hire, or as quickly after hire as feasible. b. When an employees functions or assignment of duties are changed. c. Changes in government regulation or policies and procedures occur. 4. Sanctions: Significant unauthorized or improper release of PHI by an employee or agent may result in disciplinary action up to and including termination of employment (by Excel Therapy), civil fines and/or penalties, and/or criminal sanctions (by the government), lawsuits and judgments against the employee. Such conduct by an employee or agent may also result in civil and/or criminal fines and/or penalties against Excel Therapy [See 45 CFR 164.530 e(1) & (2)]. 5. Reporting: Any employee who believes he/she has observed a violation of this policy should report it to his/her immediate supervisor or the managing owners. An employee may also report a violation anonymous or confidentially to the Compliance Alert Line at 1-888-568-8569. Calls received on this line will be referred to the Compliance Department for investigation. There will be no retaliation taken against any employee for making such a report in good faith. Effective Date: 1-1-12 Last Revision Date: 1-1-12
Please be advised that if you are receiving ANY type of Home Heath Care that will be billed to your insurance, your insurance company will not allow you to have outpatient Physical Therapy. If you start receiving Home Health Services during your treatment at Excel Therapy you must notify our office so that we can coordinate the appropriate care for your situation. If you do not inform our office, you will be responsible for payment of any denied services to our office. Thank you for your understanding and cooperation!
I give my permission for Excel Therapy to discuss any treatment, payment, or other related issues with and / or in the presence of the following person(s):
Name _________________________________________ Relationship _________________________ Name _________________________________________ Relationship _________________________ I have read and agree to the following policies set by Excel Therapy. I understand that this authorization will remain in effect unless terminated by Excel Therapy or myself. Name __________________________________________ Date _______________________________ Signed _________________________________________ Witness _____________________________