Welcome New Patients!

We are ready to get started serving you and your rehabilitation needs. Before we get going, we need information on the patient. Patient, medical, and insurance information need to be gathered so we can serve and treat you in the best way possible.

You will find a patient form below that you can fill out online. If you would rather download, print, and fill out the form via PDF download, you will find it under the fillable form. If you choose to do the latter, please scan it back in and upload it via the “Upload File” option under the form. If you are unable to scan to your computer, you can bring these forms with you to the office.

Attention! All Medicare patients need to fill out the “Medicare Patient Forms” and “New Patient Forms” in order for paper work to be completed correctly.

New Patient Form

User Information

Patient Information

Name *

First

Middle *

Middle

Last *

Last

Referring Physician *

Today's Date *

Prefix *

Mrs

Miss

Sex *

Marital Status *

Social Security Number *

D.O.B. *

(MM/DD/YEAR)

Age *

Email *

You will receive your statement at this email address!

Patient Cell Phone Number *

If patient is a student, please provide the parent's number.

Cell Phone Number Contact

Mom

Dad

Other

If this is not the patients cell phone number, please provide details

Name of "Other" if applicable

Home Phone Number *

Street Address *

City *

State *

Postal Code *

Country *

Occupation

Employer

Employer Phone Number

In Case of an emergency

Financial Agreement

Medical History Questionnaire

Patient Authorization | Consent & Release Form

Patient Name *

Patient DOB *

Release of Information & Consent & Release Form

All information provided herein is true and correct.

I am aware of my diagnosis and wish to receive treatment at this Pro Impact Physical Therapy & Sports Medicine clinic. I permit its employees and all other persons caring for me to treat me in ways they judge are beneficial to me. I understand that this care can include an evaluation, testing and treatment. No guarantees have been made to me about the outcome of this care.

I give permission to Pro Impact Physical Therapy & Sports Performance and its subsidiaries and affiliates to release information, verbal and written, contained in my medical record, and other related information, to my insurance company, rehab nurse, case manager, attorney, employer, school, related healthcare provider, assignees and/or beneficiaries and all other related persons as it relates to my treatment and/or payment for services provided.

I authorize Pro Impact Physical Therapy & Sports Performance and/or its subsidiaries and affiliates to obtain medical records and/or professional information from my physician or other medical professional as it relates to my treatment.

I consent for medical photographs to be made of me (or my child or person for whom I am a legal guardian). I understand that the information may be used in my medical record. By consenting to these medical photographs I understand that I will not receive payment from any party (Pro Impact nor patient). Refusal to consent to photographs will in no way affect the medical care I will receive. The signature below certifies that I have read and understand the above information.

Initial *

Assignment of Benefits

I authorize payment directly to Pro Impact Physical Therapy & Sports Performance, its subsidiaries and/or affiliates for services and to bill and release payment directly to Pro Impact Physical Therapy & Sports Performance, its subsidiaries and/or affiliates for any physical therapy, occupational therapy, speech-language pathology, rehabilitation, orthotic or prosthetic services provided.

This is a direct assignment of my rights assistive device benefits under this policy. A photocopy of this assignment shall be considered as effective and valid as the original.

Initial *

Notice of Privacy Practices (HIPAA Acknowledgement)

I hereby acknowledge that I have received a copy of The Notice of Privacy Practices for Pro Impact Physical Therapy & Sports Performance, its subsidiaries and /or affiliates.

In addition, I hereby consent to the use and disclosure of my personal health information for the purposes of treatment, payment, and health care operation.

Initial *

Payment Guarantee

I agree to pay Pro Impact Physical Therapy & Sports Performance, its subsidiaries and/or affiliates for the services provided to me or the party named above. If any law, such as workers’ compensation, or an insurance contract prohibit payment for these services I will cooperate and assist in the provision of information and authorizations, released, or any other type of information necessary to allow for speedy collection from my third-party payer. Where the law or an insurance contract does not prohibit payment by me, I acknowledge responsibility for any and all account balances.

Pro Impact files your insurance as a courtesy but you are still financially responsible. The Eligibility and Benefit form provided by some insurance companies is only an explanation of coverage. This is not a guarantee of payment by the insurance company. If the information provided by my insurance company is not accurate or the insurance company changes its coverage, I will be responsible for payment of all services.

If arbitrary determination of a participating insurance company indicates that a treatment or procedure is not medically necessary, the patient or patients guarantor will be responsible for the remaining balance. However, it is ultimately the responsibility of the patient or patient’s guarantor to know and understand their benefits prior to starting physical therapy.

FINANCIAL AGREEMENT: I fully understand that I am responsible for any and all charges associated with my account and that if I fail to pay any amount due, I will also be responsible for court costs, attorney fees, and collection fees of up to 33% of the amount due, incurred in the collection of any balance due. I give permission to Pro Impact and any of Pro Impact's vendors, which include collection agencies, attorneys and billers, to contact me on the cell phone numbers I have provided on matters related to my account. I understand that an automated dialer may be used to contact me by these parties and agree to allow them to do so.

I further understand that this agreement is binding regardless of any legal transaction currently in progress or initiated during or after the course of my treatments unless agreed to in writing by myself and a representative of Pro Impact Physical Therapy & Sports Performance and/or its affiliates or subsidiaries.

I understand that three statements will be generated in the course of an outstanding balance. After which, a final notice prior to collections will be mailed. Payment in full is expected on outstanding balances. If a payment plan is absolutely necessary, the terms and conditions will be determined by Pro Impact Physical Therapy and Sports Performance owner, not upon the financial plan determined by the client. I further understand and agree that, in addition to all amounts owed for services, which I will be responsible for all costs of collection including, but not limited to, attorney’s fees, court cost, filing fees, and any other costs associated with or related to collection efforts instituted by Pro Impact Physical Therapy.

Initial *

Parent or Guardian Signature *

Today's Date *

(MM/DD/YYYY)

Cell Phone Consent Form

"I... *

state your name here

..., “Consumer” understands that it is important for Pro Impact Physical Therapy “Service Provider” or an Authorized Entity (as defined below) to be able to communicate with me and have current information about me, my address, my phone number(s), and any other information about me that may assist Service Provider or an Authorized Entity in locating me or communicating with me. In consideration of Service Provider or Authorized Entity providing me services and other good and valuable consideration the receipt and sufficiency of which is hereby acknowledged, Consumer expressly consents and agrees to the terms and conditions contained in this Prior Express Consent Form.

Authorized Entities:

The term “Authorized Entities” shall mean the above referenced Service Provider and any related or affiliated health care provider, physician, service provider, independent contractor (including but not limited to billing services) and each of their respective successors, assigns, agents, attorneys, insurers, representatives, employees, officers, shareholders, partners, parents, subsidiaries, affiliated entities, and all agents and representatives of the previously listed persons/entities, and all corporations, persons, or entities in privity with any of the previously listed persons/entities, including any collection agency or debt collector retained or hired by any of the previously listed persons/entities, and all corporations, persons, or entities in privity with any of them. The term Authorized Entities shall also include any person or entity conducting business or providing services relating to health care at the same physical location at which the Service Provider or any of the previously listed persons/entities conducts some or all of its business, and any person or entity Consumer is referred to by Service Provider, and any person or entity who provides health care services related to the services provided by Service Provider.

Communication Consent:

I understand that the purpose of this agreement is to authorize the delivery of calls to me, including, but not limited to, using an automatic telephone dialing system or an artificial or prerecorded voice, or calls to a telephone number assigned to a paging service, cellular telephone service, specialized mobile radio service, or other radio common carrier service, or any service for which I am charged for the call (hereinafter “Authorized Communications”). I also understand that my agreement to the terms of this Prior Express Consent Form is not a condition of any Authorized Entity’s willingness to provide services to me. To the extent permitted by applicable law, and without limiting any other rights the Authorized Entities may have, I expressly consent and authorize the Authorized Entities to communicate with me for any reason, including reasons related to the services provided by Authorized Entities or services to be provided in the future by the Authorized Entities, including collection of amounts owed for said services, via Authorized Communications at the telephone number or numbers I provide below, or that is provided on my behalf, or any phone number that any Authorized Entity obtains or finds on its own which is not provided by me. In addition, I further expressly consent and authorize the Authorized Entities to communicate with me via SMS text messages, other forms of electronic messages, electronic mail, or other electronic communication sent or directed to me through any medium, no matter how the Authorized Entity obtain such contact information. Any Authorized Entity may communicate with me using any current or future means of communication, even if those means are not now known to the Authorized Entity or Consumer. I authorize any and all of the communication methods described in this paragraph even if I will incur a fee or a cost to receive such communications. I further promise to immediately notify the Authorized Entity if any telephone number or email address or other unique electronic identifier or mode of communication that I provided to any Authorized Entity changes or is no longer used by me. I agree that the consent and authorizations I have provided herein may be revoked only in writing addressed to the Service Provider and any Authorized Entity. Finally, I understand that the Authorized Entities have relied upon my statements contained herein and, on my promise, to fulfill my obligations contained herein.

I hereby consent and authorize that a photocopy of this authorization may be considered as valid as the original.

This Consent shall ensure to the benefit of and be binding upon my heirs, agents, spouses, executors, administrators, successors, and assigns. I intend for all Authorized Entities to be third party beneficiaries of the consent I have provided herein.

Patient Name *

Signature *

Today's Date *

Home Phone Number

(if applicable)

Cell Phone Number *

000-000-0000

If you are human, leave this field blank.

PDF Versions of the Forms:

Medicare Patient Therapy Questionnaire

Medicare Financial Responsibility Disclosure

Patient Referral Form

Notice of Privacy Practices

MEDICARE PATIENT NOTICE

Beginning January 1, 2006, the Government has imposed a financial limitation on the dollar amount that the Medicare Program will reimburse for outpatient therapy services received in a calendar year. This has been referred to as the Medicare “therapy cap.” The Government has created many exceptions that are available to patients so that therapy services in excess of the financial limitation may be provided for those patients that need those therapy services.

Exceptions

For the period January 1, 2016 to December 31, 2016, Medicare has set the following Financial Limitations:

For Physical Therapy or Speech Therapy services (combined) provided to you during 2016, the therapy cap is set at $1,960, which means that Medicare will pay a maximum of $1,568 for physical/speech therapy services provided to you in 2016, with the remaining $392 co-insurance payable by you or your supplemental health insurance. This payment amount is also subject to your annual $166.00 Part B deductible.

For Occupational Therapy services provided to you during 2016, the therapy cap is set at $1,960, which means that Medicare will pay a maximum of $1,568 for occupational therapy services provided to you in 2016, with the remaining $392 co-insurance payable by you or your supplemental health insurance. This payment amount is also subject to your annual $166.00 Part B deductible.

Each of the two therapy caps listed above is separately applied and measured – and each is based only on services received in 2016.

Financial Limitation

There are many exceptions to the therapy caps that allow patients to receive covered therapy services beyond the therapy cap dollar amount indicated above. If an exception is available, the therapy cap will not apply. Your therapist will discuss this with you to determine whether you may qualify for Medicare coverage beyond the therapy cap.

On October 1, 2012, Medicare implemented a new manual medical review process for some therapy services. If this new process affects you, your therapist will discuss it with you and answer your questions.

If none of the exceptions applies to you and you require additional therapy services above the financial limitation, your therapist will discuss with you your options so that you can make the best decision regarding your continued treatment.

Your care and treatment is paramount to us, and we will help you receive all of the therapy services that you require.

Medicare Patients

Welcome New Patients!

Medicare Patient – Therapy Questionnaire

New Patient Form

Patient Information

In Case of an emergency

Insurance Information

Financial Agreement

Medical History Questionnaire

Patient Authorization | Consent & Release Form

Release of Information & Consent & Release Form

Assignment of Benefits

Notice of Privacy Practices (HIPAA Acknowledgement)

Payment Guarantee

Cell Phone Consent Form

Authorized Entities:

Communication Consent:

PDF Versions of the Forms:

MEDICARE PATIENT NOTICE

Exceptions

Financial Limitation

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Welcome New Patients!

Medicare Patient – Therapy Questionnaire

New Patient Form

Patient Information

In Case of an emergency arrowup6

Insurance Information arrowup6

Financial Agreement arrowup6

Medical History Questionnaire arrowup6

Patient Authorization | Consent & Release Form arrowup6

Release of Information & Consent & Release Form

Assignment of Benefits

Notice of Privacy Practices (HIPAA Acknowledgement)

Payment Guarantee

Cell Phone Consent Form arrowup6

Authorized Entities:

Communication Consent:

PDF Versions of the Forms:

MEDICARE PATIENT NOTICE

Exceptions

Financial Limitation

↑

In Case of an emergency

Insurance Information

Financial Agreement

Medical History Questionnaire

Patient Authorization | Consent & Release Form

Cell Phone Consent Form