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ISSUE:
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ONSET OF SYMPTOMS:
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INITIAL APPT DATE:
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MM slash DD slash YYYY
INITIAL APPT TIME:
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:
Hours
Minutes
AM
PM
AM/PM
INITIAL APPT PROVIDER:
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Personal Information
FULL NAME:
*
First
Last
BIRTHDATE:
*
MM slash DD slash YYYY
PHONE:
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EMAIL ADDRESS:
*
SECONDARY PHONE:
REFERRED BY:
*
EMERGENCY CONTACT NAME:
*
First
Last
EMERGENCY CONTACT PHONE:
*
ANY PREVIOUS PT APPTS IN PAST YEAR:
ARE YOU CURRENTLY RECEIVING IN-HOME REHABILITATION?
*
YES
NO
INSURANCE
METHOD OF PAYMENT:
SELF
HEALTH INSURANCE
PIP
WORKER’S COMP
LAWYER
OTHER
IF OTHER, PLEASE LIST:
PRIMARY INSURANCE:
POLICY/ MEMBERSHIP NUMBER:
GROUP NUMBER:
PHONE:
GUARANTOR NAME (IF STUDENT/MINOR):
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Last
RELATION TO PATIENT:
BIRTH DATE (GUARANTOR):
MM slash DD slash YYYY
START MONTH/PLAN YEAR:
DO YOU HAVE SECONDARY INSURANCE?
YES
NO
SECONDARY INSURANCE:
POLICY/MEMBER NUMBER:
GROUP NUMBER:
PHONE:
MVA RESPONSIBLE PARTY INFORMATION
AUTO INS CO.:
ADDRESS:
Street Address
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Switzerland
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Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
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US Minor Outlying Islands
Uganda
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United Kingdom
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Venezuela
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Virgin Islands, U.S.
Wallis and Futuna
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Zambia
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Åland Islands
Country
PHONE:
CLAIM#:
ADJUSTERS NAME:
First
Last
ATTORNEY:
PHONE:
ADDRESS:
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
PATIENT/CLIENT RESPONSIBILITES
Megan Rich Physical Therapy (MRPT)
Do you agree to the statements below:
*
Yes
I agree to actively participate in my therapy program, including but not limited to the following:
Being prompt to my appointments/classes, signing in, paying co-pays, balances, drop in rates upon arrival.
Being discharged and referred back to my physician if I “no show” or cancel three (3) consecutive appointments. All future scheduled appointments will be cancelled.
Complying with a mutually agreed upon treatment plan.
Providing feedback to my therapist regarding my well-being and taking responsibility to improve my condition.
Giving 24-hour notice to cancel MRPT appointments. Without 24-hour notice, you will be charged $35.00 per 30 minute PT appointment and $75 per 60 minute appointment.
SIGNATURE OF PATIENT/GUARANTOR:
*
First
Last
CONSENT TO PARTICIPATE IN MOVEMENT THERAPY and/or RECEIVE PHYSICAL THERAPY SERVICES
MRPT has made available facilities and equipment for the benefit of its clients. This document will help you understand the risks associated with participation so that you may make an informed decision with regard to your participation.
Risk:
If you elect to use the fitness area or any portion of this facility or if you elect to participate in any related programs, your use and participation will be solely at your own risk. You are advised to consult with your personal physician before beginning to use the fitness area or participating in any related activity. In addition, if deemed advisable by your physician, you should consult with him/her on an ongoing basis. Trainers/teachers/therapists are trained in fitness program management, but are not physicians. Trainers/teachers/therapists lease space used as the fitness area and are in no way owners. You should not view their assistance, or any results of any exercise assessments, as medical diagnosis or statement about your health. Moreover, the trainer/teacher/therapist will not be responsible for monitoring individual use of the fitness area, but will provide assistance. Even consultation with your physician and engaging in regular exercise in no way guarantees against the possibility of adverse occurrences during exercise sessions or use of other fitness area facilities. Possible risks include, but are not limited to, episodes of dizziness, fainting, muscle and skeletal injury, sprains, heart attack, stroke, or sudden death. Please contact your physician for further details.
Release:
As a condition precedent to your right to use the fitness area and participate in programs offered, you must sign below. Please read this form carefully and make sure you fully understand it before signing.
Signature:
I have read and understand the descriptions and risks described herein. Any questions that have occurred to me have been raised and have been answered to my satisfaction. I consent to receive training rendered at the BMI and physical therapy at MRPT.
SIGNATURE OF PATIENT/GUARANTOR:
*
First
Last
PATIENT AUTHORIZATION AND ASSIGNMENT OF BENEFITS
NAME:
*
First
Last
INSURANCE:
*
I [name, listed above], hereby authorize MRPT to apply for benefits from [insurance, listed above] for payments to be made directly to MRPT. In the event that MRPT is not a provider of care with your insurance carrier then I agree to pay directly at time of service for the session(s). MRPT will supply me with the bill including the diagnosis code, CPT codes, or other so I can submit the bill myself for reimbursement. I certify that the information I have reported with regard to my insurance is correct and further authorize the release of any necessary information, including medical information for this and any related claim, to the named insurance company. I permit a copy of this authorization to be used in place of the original. Either the above carrier or I may revoke this authorization at any time, if in writing to MRPT. I hereby authorize payment of medical benefits directly to MRPT, if any otherwise payable to me for services described by the therapist’s billing information. I understand the limits of my insurance company(s) and/or Medicare.
I understand that I am financially responsible for all charges not covered by this authorization including balances due after 60 days of billing, as well as any co-payments and deductibles as per the terms specified by my insurance carrier paid in full at the time of services. If for any reason the workers’ compensation claim is found non-condensable, I will accept full responsibility for any charges incurred. I understand that durable medical equipment (DME) is paid for at the time of purchase and is not returnable or refundable. I understand that I will be charged $30.00 per 30 and $75.00 per 60 minute appointments if 24-hour notice is not given prior to not showing, canceling or rescheduling.
SIGNATURE OF PATIENT/GUARANTOR:
*
First
Last
DATE:
*
MM slash DD slash YYYY
HIPAA NOTICE OF PRIVACY PRACTICES
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care options (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. By signing below, I acknowledge I have access to a full copy of this Notice of our Privacy Practices. I also acknowledge that my information may be shared with non-healthcare professionals employed by MRPT for purposes of providing care in the continuum of services.
SIGNATURE OF PATIENT/GUARANTOR:
*
First
Last
DATE:
*
MM slash DD slash YYYY
POOL WARM-WATER WAIVER
MRPT maintains a therapy pool water temperature of 90-92 degrees Fahrenheit. Research shows that for an active, recreational water exercise program that incorporates flexibility, stretching, muscle strengthening and endurance activities, the appropriate and safe water temperature range is 83-90 degrees Fahrenheit. Ill effects that may occur in higher water temperatures include increased core body temperature, blood pressure changes, increased oxygen consumption, cardiac demands beyond a safe margin and increased risk of cardiovascular incidents for people with chronic health conditions. Please sign below indicated that you have read and understand the descriptions and risks described herein and also acknowledge there is
NO LIFEGUARD ON DUTY
.
SIGNATURE OF PATIENT/GUARANTOR:
*
First
Last
DATE:
*
MM slash DD slash YYYY
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