Patient Registration – with online form

If you are a new patient, please download our new patient packet, or you can fill out the forms below and they will be sent to our office. All information is confidential

Patient Registration Information

 

MaleFemale

SingleMarried

Is your injury the result of an accident? YesNo If yes, was it work relatedmotor vehicle accident Other

Appointment Reminders will be sent via Text Messaging. Please state your service provide

Insurance Information

Worker’s Compensation Information

Claim Number

Case Manager

Case Manager Phone

Date of Injury

Employer at time of injury

Employer Phone Number

RELEASE OF INFORMATION
I give permission to Jeff Kitchen, Inc. (Rehab Plus) to release information to my insurance company, a
ttorney, assignees, and/or beneficiaries.
ASSIGNMENT OF BENEFITS
I authorize payment directly to Jeff Kitchen, Inc for services I receive. Any payments made to me by
third party payer services provided by Jeff Kitchen, Inc. will be immediately (within 5 days) transferred to
Jeff Kitchen, Inc.
PAYMENT GUARANTEE
In consideration of the services rendered and to be rendered to the above named patient by Jeff Kitchen, Inc expressly guarantee payment of this account and agree to pay any charges left unpaid in whole or in part by the insurance company. Should this account proceed to collection agency or court, I will be responsible for both the cost of billed services, as well as cost of collections and any and all attorney and court fees associated with the collection process.
The patient is ultimately responsible for account totals and balances. A $10 processing fee is applied
for each subsequently mailed statement..

Patient or Responsible Party Signature

*By typing in the field above, you authorize this e-signature to be valid and accurate.
Date
Patient Medical History Form
Name
Age
Occupation
(Type of work, examples: lifting, prolonged sitting, standing, etc. )
Injury/Reason you are here?

If you had surgery for this injury, what was the date of surgery?

Past Medical History :

Do you have any previous history of:

Diabetes
YesNo
Pulmonary Disease
YesNo
Cancer
YesNo
Pacemaker
YesNo
Blood Pressure Problems
YesNo
Asthma
YesNo
Seizures
YesNo
Knee Surgery
YesNo
None Significan
Heart Disease
YesNo
Back Surger
YesNo
Other


Which of the following aggravates your condition?:

Walking
Bending
Change of Direction
Lying Prone
Overhead Activities
Standing
Lifting
Up Stairs
Lying Supine
Impinging Positions
Sitting
Running
Down Stairs
Sidelying
Prolonged Immobility


What eases your symptoms?

Resting
Medication
Supine with feet elevated
Other
Avoidance
Walking
Frequent change of position
Modalities
Standing
None


Have you been admitted to the hospital or had any surgical procedures during the last 5 years: YesNo

What was this condition? :

Is this condition the reason you were referred to physical therapy? : YesNo

Have you received any physical therapy treatments during the past 5 years? : YesNo

If yes, for what condition and was the treatment effective?

Have you had any other previous medical problems or surgeries? : YesNo

If yes, please specify:

Did you receive any special tests while in the hospital or as an out-patient? Example: CAT Scan, EMG,EKG, MRI YesNo

If yes, please specify:

Have you had any previous orthopedic problems? YesNo

If yes, please specify:

Medications? What type and what for?

Exercise/Activity level:
0 days/week 1-2 days/week 3-5 days/week

6-7 days/week

What types of activities?

Name of your orthopedic and/or primary doctor?

Patient Signature

*By typing in the field above, you authorize this e-signature to be valid and accurate.

Date

Patient Name:

Patient Name:Please mark the diagram with “xx” where your pain typically presents:

On a scale of 1 to 10, (1 being minimal pain and 10being excruciating), please rate your overall pain:

at worst:

at best:

on average::


Financial Policy and Patient Responsibility
Acknowledgement of Receipt of Notice of Privacy Practices

Rehab Plus Sport Therapy is committed to providing our patients with the highest quality care.
We thank you for taking the time to read and understand our policy.


It is the Patients Responsibility:

  • To know their insurance policy. Patients should be aware of their benefit coverage including which healthcare providers are contracted with their plan, covered and non-covered benefits, authorization requirements, and cost share information such as deductibles, co-insurance, and co-payments. If you are not familiar with your plan coverage, we recommend you contact your carrier directly.
  • To report any changes to their insurance policy, including, but not limited to cancellations, term inations, policy number changes, group number changes, etc and to supply a
    copy of the new insurance information prior to the next therapy session. Any non-covered/denied services will be the responsibility of the patient.
  • To obtain a referral from their Primary Care Physician (PCP) and/or obtain authorization for treatment from their insurance carrier prior to receiving services. Any non-covered services are the financial responsibility of the patient.
  • To pay their co-payment at the time of service.
  • To pay any Medicare deductible and co-insurance amounts not covered by supplemental insurance.
  • To promptly pay any patient responsibility indicated by their insurance carrier. If payment of that balance is not received within 30 days, we will charge a $10 processing fee for each subsequently mailed statement.
  • To facilitate in claims payment by contacting their insurance carrier when claims have not been paid.
  • To schedule all therapy appointments one week in advance and to attend all appointments and follow home instruction. Please be aware your appointments may be scheduled any day of the week (Mon-Fri) and do not have to be set in a specific pattern. (i.e. Mon-Wed-Fri)

CANCELLATION POLICY:

  • 24 hours notice is required for cancelling or rescheduling a scheduled visit.
  • If cancelling the appointment and without such notice, the patient will be charged $50.00.

  • A credit card will be kept on file and required for ALL patients.

It is Rehab Plus Sport Therapy’s Responsibility:

  • To provide quality medical care.
  • To file insurance claims as a courtesy to the patient. Claims are filed twice per month (middle and end of month). Patient statements are sent out in the first week of each month. A 60 day period will be extended for pending insurance payment,after which the patient may be held responsible forthe balance.


Financial Policy Acknowledgement and Assignment ofBenefits:


I have read and understand the above financial policy. I understand that, regardless of my insuranceclaim status or absence of insurance coverage, I am ultimately responsible for the balan
ce on my account for any services rendered. I authorize my insurance carrier(s) to make payment directly to Rehab Plus Sport Therapy (Jeff Kitchen, Inc.). Any payments made to me by third party payer services provided by Rehab Plus Sport Therapy (Jeff Kitchen, Inc.) will be immediately (within 5 days) transferred to Rehab Plus Sport Therapy (Jeff Kitchen,Inc.).

Patient or Responsible Party Signature*By typing in the field above, you authorize this e-signature to be valid and accurate.
Date



Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge receipt of HIPAA compliant Notice of Privacy Practices.

By signing above, you, as the patient or responsible party, agree to the terms and conditions listed under “Financial Policy Acknowledgement” andAssignment of Benefits”.
Any unilateral alteration, strikeover or modification to the preprinted text or line entries of this document and legal agreement shall be of no effect whatsoever, and at Jeff Kitchen Inc.’s sole discretion, may render this document invalid.

Patient or Responsible Party Signature

*By typing in the field above, you authorize this e-signature to be valid and accurate.
Date