Spencer County Physical Therapy Patient Information

February 19, 2016

Spencer County Physical Therapy Patient Information

Injury date Surgery Date

What Body Part we are seeing you for?

Patient Name DOB Age SS#

Street Address City Zip

PO Box # City Zip Home Ph

Cell Phone Employer Work Ph

Referring Doctor Family Doctor

Emergency Contact: Relation Phone

Information about the policy holder (person who pays the insurance premium)

How are you related to the policy holder?SelfSpouse / Sig. OtherParentGuardianOther

Policy Holder Name DOB SS#

Policy Holder Home Ph Work Ph Cell Ph

Past medical: Check all that apply to you (patient). If more than one item is in the box, circle which one applies to you.

Diabetes – Insulin / Meds Any Heart ProblemsUse an inhaler
Cancer / Skin CancerDo you have a pacemakerHistory of Seizures / Epilepsy
Lung / Breathing problemsEver had a stroke (CVA)Sensitivity to Heat / Ice
Latex allergyOsteoporosis (thin bones)Pregnant – Now
Had an MRI (this problem)Had a CT Scan (this problem)Had surgery (this problem)

Please list any PRESCRIPTION medication you are currently taking

I give my consent for an evaluation and treatment at Spencer County Physical Therapy (SCPT). I also assign all major medical benefits to SCPT. A photocopy of this assignment is considered as valid as the original. I authorize SCPT to release all information necessary, including medical records, to secure payment. I was given the opportunity to read SCPT’s Privacy Notice Summary and offered a copy for my records. The full document is available in the waiting room. Initials ______

It is your responsibility to know your insurance benefits and to provide us with a copy of your current insurance card. You are ultimately responsible for the entire bill. If your insurance company, including but not limited to Medicare, Medicaid, private, third party, Auto and Worker’s Compensation, does not remit payment within 90 days, or denies the claim, the balance will be due in full from you. Any unpaid balance, 30 days after you receive a bill from SCPT, will incur 2% monthly interest plus the full cost of all collection and attorney fees. Copayment, deductible, and /or co-insurance payment is required prior to treatment (at check-in). Returned check fee is $30. In the event my Worker’s Compensation or Auto claim is denied, I give authorization to bill my health insurance and agree to pay any balance due, including but not limited to, my deductible, co-payments and co-insurance. Initials ______

All equipment, except TENS units, is solely owned by SCPT and profit from sales of any product is income for SCPT. You are under no obligation to purchase any product. If you are unable to keep a scheduled appointment, you must call us to cancel. If you do not call prior to your appointment time, you (not your insurance company) will be charged $25.00 per occurrence. I agree to pay this fee. Initials ______

How did you hear about us? (Check all that apply):

DoctorPrevious PatientFamily/FriendSign on BuildingPhone BookNewspaperWeb SearchFacebook

I have read the above information, or it has been explained to me. I understand all of my financial responsibilities and agree to accept and pay for physical therapy services as prescribed by agents of SCPT.



_____________________________MR # (office use only) Rev. 1-2016