Patient Intake Form

HOURS OF OPERATION:
Weekday appointments are offered 9am-6pm Monday-Thursday and 9am-3pm on Fridays (admin staff 8:30am-1pm Fridays).

COPAYMENTS ARE TO BE PAID AT THE TIME OF APPOINTMENT. During normal business hours, the front desk will collect your copay. If you are scheduled after 1:00pm on Friday’s, your copay will be charged Monday morning.

Our phone lines are answered during our normal business hours Monday and Wednesday 8:30am-6:00pm, Tuesday and Thursday 9:30-6:00pm, and Friday’s 8:30am-1:00pm. Please check in with the front desk upon your arrival. If you are more than 15 minutes late, you may be asked to reschedule your appointment.
If you are scheduled outside of our normal business hours, our front desk will not be present when you arrive. Please take a seat in the lobby when you arrive and your therapist will greet you at the time of your appointment.

During regular business hours, you will speak directly with one of the clerical staff. On rare occasions, all lines may be in use during the time of your call and you may hear a recorded message. Please leave a message and we will return your call as soon as possible.

Please initial here that you have read and understand our office hours and copay policy _____________

Patient First Name

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Patient Last Name

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Patient Gender

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If child, Parents’ Names:

Mother

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Mother’s Cell

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Father

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Father Cell

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Patient SS#

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Patient Date of Birth

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Patient Address

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Phone #

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How did you hear about Performance UNLIMTIED?

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Backup Phone #

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Patient Marital Status:

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If student, name of school

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Is patient employed?

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Patient Employer

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Full Time

Part Time

Emergency Contact

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Relationship

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Emergency Contact Phone Number

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Primary Care Physician

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Phone Number

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PCP Address

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Insurance Company

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Insurance Co. Phone

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Insurance Company Claims Address

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Name of Insured

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Relationship to Patient

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Insured birthdate

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Insured SS#

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Patient’s Identification #

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Group#

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Insured’s Employer

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Is the patient taking any medications?

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If yes, list?

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Does the patient have any allergies?

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If yes, list?

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Has the patient had any surgeries?

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If yes, list?

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Have you EVER been diagnosed as having any of the following conditions

Cancer

Heart Problems

High Blood Pressure

Circulation Problems

Asthma

Emphysema/Bronchitis

Thyroid Problems

Diabetes

Multiple Sclerosis

Rheumatoid

Depression

Hepatitis

Anxiety

Kidney Disease

Stroke

Anemia

Epilepsy

Patient or Authorized Representative Signature: I certify that all of the above information is correct. I voluntarily consent to receive treatment or have my minor child receive treatment at Performance UNLIMITED Physical Therapy. I authorize the release of any medical or other information necessary to process any insurance claims filed on behalf of myself or my minor child. I also request that payment of benefits or services received be rendered directly to Performance UNLIMITED Physical Therapy. In the event that payment is made directly to the insured, I understand that I am personally responsible for payment of services rendered, unless the insurance check is presented to Performance UNLIMITED Physical Therapy endorsed with the insured’s signature and the words “payable to Performance UNLIMITED Physical Therapy” as soon as it is received.

Signature of Patient (or legal guardian, if patient is under 14)

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Date

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Signature of Minor Child (ages 14-18 only)

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Date

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UNDERSTANDING YOUR COSTS:
While PUPT strives to make sure all of your financial obligations for services are clearly explained to you, it is your responsibility as a patient to understand what your insurance covers and does not cover. PUPT recommends you contact your insurance company by calling the number listed on the back of your insurance card and inquire about your physical therapy benefits, allowing you to be aware of any costs that may become your responsibility as part of your treatment with us. By voluntarily consenting to receive our services, you acknowledge that you are personally responsible to pay PUPT in full for services not covered by your health insurer.

SCHEDULING AGREEMENT/NO SHOWS AND LATE CANCELATIONS:
In order for PUPT to schedule you in a timely manner and allow for timely follow-up appointments, it is your responsibility to communicate when you are unable to keep your appointment not only as a courtesy to your provider and other patients, but also for administrative purposes as our staff prepares for each and every patient visit. A 24-hour advance notice is required to cancel a scheduled appointment. Failure to comply with this policy and for non-attendance of scheduled session will result in a $75 fee.

OUTSTANDING BALANCES:
It is the policy of PUPT that the patient should not exceed a balance of $250. If your patient responsibility balance becomes greater than this threshold, you will receive a courtesy call from the billing department. At this time, a payment agreement may be offered and must be followed to continue your treatment with us. We will work with you to develop an affordable payment plan that both reduces your balance and meets any budget limitations you may have. However, if at any time it is determined that good faith payments are not being made on your accounts as agreed, PUPT reserves the right to discontinue services until your account is current.

RETURNED CHECKS:
A fee of $30 will be charged to your account for a check returned to us for any reason.
ALL FEES ARE SUBJECT TO CHANGE

STATEMENTS:
You will receive a monthly billing statement if a balance exists for you, which you are responsible as determined by your health insurer. The balance due may include deductibles, missed copays, coinsurance, denied claims, fees, and any other services requested that are not covered by your health insurer. Payment is due within 30 days of receipt. You will be asked at your next appointment to pay any outstanding balance in full unless prior arrangements have been made.

DELINQUENCY:
If your account should become delinquent, you will be responsible for finance charges of 2.5% for each month we do not receive payment. Minimum finance charge is $5.00. Should the amount remain unpaid, the balance plus 35% for collection fees will be transferred to a collection agency.

COMMUNICATION:
PUPT strongly believes that a good therapist/ patient relationship is based upon understanding and open communication. If you have questions about bills that you receive or you have the need to make payment arrangement due to hardship, loss of insurance, job, or other, please contact our billing department and we will be happy to assist you in your options for continuing care.
MINOR CHILDREN:
The parent(s) or legal guardian who brings a child to a therapy appointment is responsible for payment on this account. It is our policy to consider an 18-year-old who is still in high-school a “minor” for billing purposes. Charges for minor children will be billed to the parent whom the patient resides.

PERSON(S) FINANCIALLY RESPONSIBLE FOR ACCOUNT: I (we), the undersigned, hereby agree to be financially responsible for this account and agree to the above terms.

Name

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Social Security #

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Address

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Signature

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Date

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Name

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Social Security #

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Address

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Signature

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Date

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CREDIT CARD AUTHORIZATION

I authorize Performance UNLIMITED Physical Therapy to charge my credit card for any patient responsibility amount after claims are submitted and processed by my insurance company. These balances may include copayments, coinsurance, deductibles, and other services. By signing below, you acknowledge that you have read PUPT’s financial agreement policy.

Upon the termination of services, I understand that my credit card will be charged any remaining balance owed unless another payment arrangement has been agreed upon. I also understand if my card declines and I have not made payments towards my balance in 120 days, my account is considered inactive and may be sent to a credit collections agency.

Patient Name (please print):

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Date:

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Credit Card Type:

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Name on Credit Card

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Relationship to Patient

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Credit card number

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Expiration date

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CVV

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Billing Address

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Zip Code

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PLEASE INITIAL:

Missed appointments and late cancellations will be charged on your credit card according to the policies and fees specified on PUPT’s financial agreement.

If you dispute your bill, we will always be happy to work with you to understand if there is a mistake. We will refund your credit card if your insurance company has made a billing error. We will only charge your credit card the amount we are instructed to by your insurance company in the EOB they send to us.

Signature

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Date

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FINNANCIAL AGREEMENT

Patient name

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Birhtday

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FORM OF PAYMENT FOR SERVICES RENDERED:

I (we) will personally pay each charge in full

I (we) choose to have charges submitted to insurance and pay amounts not paid by insurance.

It is the policy of PUPT to collect payment in full for services rendered at the beginning of each appointment. Insurance and copayments are due at the time of service or a $5.00 fee will be added to cover billing costs.

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES AND CONSENT TO USE AND DISCLOSE HEALTH INFORMATION.

Patient name

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Birthday

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I have been informed of the Privacy Practices of Performance UNLIMITED Physical Therapy and Performance UNLIMITED Physical Therapy is authorized to use and disclose health information for treatment, payment, and healthcare operation purposes consistent with its Notice of Privacy Practices.

Signature

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Date

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Printed name of legal representative (If applicable)

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Relationship to patient

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AUTHORIZATION TO DISCLOSE INFORMATION TO PRIMARY CARE PHYSICIAN

Patient name

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Birthday

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Insurance companies require us to ask you whether we can notify your primary care physician regarding your treatment at Performance UNLIMITED Physical Therapy. Some facets of treatment require coordination between healthcare providers. The decision is entirely up to you, but is recommended to maintain overall good health. Please complete the bottom portion of this page. Check the appropriate line regarding coordination if care by checking the appropriate response. This authorization will remain in effect unless otherwise revoked by you. To revoke authorization, please submit your request in writing, ATTN: Compliance Officer.

I hereby Authorize Performance UNLIMITED Physical Therapy to release to my primary care physician any information deemed necessary by my therapist.

Printed patient name

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Physician Name

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Physician Address

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Refuse to authorize Performance UNLIMITED Physical Therapy to release to my primary care physician any information deemed necessary by my therapist.

Signature

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Date

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Signature

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Date

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ACKNOWLEDGMENT: NOTICE OF PRIVACY PRACTICES AND HIPPA

I hereby acknowledge that I have reviewed and received a copy of Performance Unlimited Physical Therapy by Dan Glatz’s Notice of Privacy Practices attached here to explaining:

How Performance Unlimited will use and disclose my protected health information
My privacy rights with regard to my protected health information
Performance Unlimited’s obligations concerning the use and disclosure of any protected health information

Performance Unlimited Physical Therapy will share this information with individuals and providers you choose in order to coordinate your care, provide medical and case management and health coaching services, discuss your treatment, or discuss payment. This information may then be further disclosed.

Please check any of the following that pertain to your Personal Health Information and Performance Unlimited:

Performance Unlimited may use email to communicate PHI with me.

Performance Unlimited may use cellular, texting, or another SMS to communicate PHI with me.

Performance Unlimited may share my information with anyone that answers my phone Performance Unlimited may share my information with the following people:

First Name

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Last Name

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Relationship to Client

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First Name

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Last Name

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Relationship to Client

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First Name

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Last Name

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Relationship to Client

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Performance Unlimited may NOT share my information with anyone. Performance Unlimited can only discuss my treatment, the payment for services with me—the client—my physician(s) and insurance company

I agree to the consent to share information with Performance Unlimited. I also understand that if I have any questions or complaints, I may contact Daniel Glatz at 724-816-3583 or email danglatz@performanceuntld.com

PERFORMANCE UNLIMITED PHOTO/VIDEO RELEASE

Name of Client of Personal Representative:

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I, the above-named individual (the “Client/Attendee”), agree that Performance Unlimited Physical Therapy may collect and obtain data as a result of my participation in, or training of, any of the Facility’s service offerings. These service offerings include but are not limited to: physical therapy services including treatment, demonstrations, testimonials, conversations, as well as use of the fitness equipment. I further agree that the Facility may use such data in reports or publications and that my identity may be used in reports, publications or advertisements for the Facility, provided they do not violate any bylaws or responsibilities defined by the NCAA.

Data includes but is not limited to DVDs, Videos, brochures, posters, website, or social media postings. I understand my name will not be used without my permission.

Please mark here if you agree with the terms and conditions set forth above.

Please mark here if you DO NOT agree with the terms and conditions set forth above.

Name of Patient of Personal Representative:

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Signature

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Date

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