You are on page 1of 10

Excellent Care. Exceptional Results.

CONSENT TO TREAT MINOR CHILDREN


Please print all information

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? ______________

Do you have now or ever been diagnosed with:


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:

Weight loss / gain Fatigue Fever / chills / sweats Night sweats

Nausea / vomiting Dizziness Pain at night Difficulty sleeping

Weakness Shortness of breath Difficulty swallowing


Difficulty concentrating

Numbness / tingling Headaches Change of appetite Falls

Please rate your health:

Excellent

Good

Fair

Poor

Do you exercise? YES NO

If yes, how often _________________________________

What type of exercise? _____________________________________________________ Was the onset due to: Injury Motor vehicle accident Slow onset Chronic Work related

Repetitive motion Sports Recreational Trauma Unknown Other ___________


Briefly describe why you are here today, (Describe the condition and date of onset):
_________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ ___

Diagnostic testing Performed: Nerve conduction velocity EMG Bone scan MRI

Cardiac stress test CT scan Blood test Urinalysis Doppler studies x-rays

Other______ Results from testing: ________________________________________________________________

What is your pain intensity on average? (0 = no pain, 10 = worst imaginable)__________________


At its worst _________At its best __________At rest __________ At night _________Movement___________ Movements that increase pain ________________________Movements that decrease_____________________ Does the pain radiate and if so where: ___________________________________________________________ When is the pain the worst: Morning / Afternoon / Night Please indicate where your pain or symptoms are by shading areas below: Describe the Pain (Mark all): Sharp Dull Achy Burning Stabbing Throbbing Pulsating Deep Boring Shooting Searing Radiating Tearing Terrifying Ripping Other___________

Do you have: Pins and needles Numbness Tingling Loss of sensation Hypersensitivity

Strength loss? If so, where:_______________________________________________________________


What are your goals for Physical Therapy? ________________________________________________________________________________________ ________________________________________________________________________________________ I certify that the above information is correct to the best of my knowledge. I have disclosed all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that these services are a health aid and not a substitute for a doctors care.

Signature:___________________________________________________ Date:______________

Excellent Care. Exceptional Results.

Patient Information
Acct #:____________ Appt Date:_____/_____/_____ Completed by:________________ Name: _____________________________________________________
Last Street First City MI

Address: ____________________________ __________________

______
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_________________________

For Office Use Only


________________________________ __________________________________________________ Primary Insurance Carrier Address ID#:______________________________ Eff. Date:______/______/______ Group #:_______________ Policy Holder:________________________________________________________________________
Last Address First DOB MI Employer

____________________________________________ _____/______/_______ _________________ 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_________________________

Excellent Care. Exceptional Results.

CONFIDENTIALITY OF PROTECTED HEALTH INFORMATION


Purpose To establish a mechanism to protect the confidentiality of individually identifiable patient health and financial information from any unauthorized intentional or unintentional use or disclosure in accordance with the requirements in the HIPAA Privacy Rule (See 45 CFR 164.530). Procedure A. Individually Identifiable Information Protected Health Information (PHI) may not be disclosed or released without a complete and valid written authorization signed by the patient, parent, or legally authorized representative, unless (1) the use of such PHI is for purposes of treatment, payment, or healthcare operations, generally, or (2) release of the PHI is specifically allowed by State or Federal law without a valid authorization. The HIPAA Privacy Rule specifies the following 18 pieces of Individually Identifiable Information information that, when linked with health or medical information, constitute PHI (45 CFR 164.514): 1. Names of the individual, and relatives, employers, or household members of the individual. 2. Geographic identifiers of the individual, including subdivisions smaller than a state, street addresses, city, county, and precinct. 3. Zip code at any level less than the initial three digits; except if the initial three digits cover a geographical area of 20,000 or less people, then the zip code is considered an identifier. 4. All elements of dates, except year, or dates directly related to an individual including birth date, admission date, discharge date, date of death and all ages over 89 and all elements of dates (including year) indicative of age, except that such ages and elements may be aggregated into a single category of age 90 or older. 5. Telephone numbers. 6. Fax numbers. 7. Electronic mail addresses. 8. Social Security Numbers (SSN). 9. Medical record numbers. 10. Health plan beneficiary numbers. 11. Account numbers. 12. Certificate / license numbers. 13. Vehicle identifiers and serial numbers. 14. Device identifiers and serial numbers. 15. Web Universal Resource Locators (URLs). 16. Internet Protocol (IP) address numbers. 17. Biometric identifiers, including finger and voice prints. 18. Full-face photographic images and any compatible images. 19. Any other unique identifying number, characteristic, or code. B. Patient A patient is any individual who seeks and / or receives services from Excel Therapy, LLC. Effective Date: 1-1-12 Last Revision Date: 1-1-12

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

Effective Date: 1-1-12 Last Revision Date: 1-1-12

Excellent Care. Exceptional Results.

PAYMENT POLICY INSURANCE AGREEMENT


I understand that I will be financially responsible for all services received. I agree to pay any amount not covered by my insurance. I understand that Excel Therapy accepts no responsibility regarding what the insurance company will or will not pay. I authorize any assign payment of all benefits directly to Excel Therapy. I understand that if my patient balance from Excel Therapy goes to a collection agency or an attorney for collection, Excel Therapy may elect to assess a fee up to the maximum allowed by law. I authorize the release of any information to my insurance company that they may need in order to process my claims.
As a courtesy, Excel Therapy may attempt to assist you with contacting your insurance for coverage verification; however, every plan/policy is unique to each individual. It is ultimately your responsibility to contact your insurance company to determine if services will be covered and how they will be covered.

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!

AUTHORIZATION TO RELEASE INFORMATION FROM EXCEL THERAPY TO ANOTHER PHYSICIAN


I understand that there may be times that Excel Therapy may need to refer me to another physician / provider for further medical care. I authorize Excel Therapy to release the medical records and / or information needed to the provider to whom I have been referred.

POLICY ON CONFIDENTIALITY AND PRIVACY


I have read (or been given the opportunity to read) Excel Therapys Policy on Confidentiality and Privacy (the blue laminated sheet) and understand its contents. I understand that Excel Therapy makes every effort possible to follow the HIPPA laws regarding my privacy. In keeping with the law, I agree to the following: I give my permission for Excel Therapy to leave a message for me. I give my permission for Excel Therapy to contact me by E-mail. I give my permission for Excel Therapy to remind me of upcoming appointments. YES YES YES NO NO NO

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 _____________________________